NCLEX Practice Exam/Test - Level of Cognitive Ability (Analysis 1-5)

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1. A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because the client:

a) has renal failure
b) requires nasogastric suction
c) has a history of Addison's disease
d) is taking a potassium-sparing diuretic


2. A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. Which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?

a) U waves
b) absent P waves
c) elevated T waves
d) elevated ST segment

3. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?

a) the client with colitis
b) the client with Cushing's syndrome
c) the client who has been overusing laxatives
d) the client who has sustained a traumatic burn

4. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

a) ST depression
b) inverted T wave
c) prominent U wave
d) tall peaked T waves

5. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of sodium value at this level?

a) the client with renal failure
b) the client who is taking diuretics
c) the client with hyperaldosteronism
d) the client who is taking corticosteroids



ANSWERS AND RATIONALE

1) B
 - potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.

2) A
- a serum potassium level lower than 3.5 mEq/L indicates hypokalemia. Potassium deficit is a common electrolyte imbalance and is potentially life threatening. Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia.

3) D
- a serum potassium level higher that 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stage of massive cell destruction such as trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

4) D
- a serum potassium level higher that 5.1 mEq/L indicates hyperkalemia. Electrocardiogram changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.

5) B
- hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hypoaldosteronism are at risk for hypernatremia.


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NCLEX Preparation Course - Critical Thinking Exercises VI (Answers 41-50)

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Here are the Questions to NCLEX Preparation Course - Critical Thinking VI (41-50) --> 



41) A- the nursing assistant is allowed to assist client out of bed using Hoyer lift. Catheterization, change of dressing should be done by the LPN/LVN. Providing psychosocial care is done by the RN.

42) A
- suction should be applied only during withdrawal of the catheter, not during insertion. This is to prevent trauma to the mucous membrane of the airway. Therefore choice A requires intervention by the nurse. Whe nursing action is incorrect, it requires intervention.

43) C
- a diagonal figure-of-eight bandaging ensures conical shape of the stump. This will facilitate prosthesis fitting.
Choices A, B, D are incorrect actions by the LPN/LVN when wrapping a stump. Therefore, these actions would require intervention by the nurse.

44) D
- following-up tasks delegated to LVN is a responsibility of the RN. A status report will be used as a basis as to what help is needed by the LPN/LVN.

45) A
-the CNA/UAP is competent in setting up Bryant's traction. Choices B, C (nursing process) will be done by the RN. Choice D will be done by the LVN.

46) D
- ethical dilemmas are addressed by the American Nurses Association's Code for Nurses.

47) A, D, and F
- the RN performs phases of the nursing process. Clients who need assessment, health teachings, evaluation and those with unstable conditions should be cared for by the RN.
Choices B, C, and E will be delegated to the LPN/LVN, the "technical doer."

48) A
- causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiration or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigation, is at risk for excess fluid volume.

49) D
- assessment findings in a client with deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in option A, B, and C are seen in a client with excess fluid volume.

50) B
- the causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.


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NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 41-50)

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NCLEX Preparation Course - Critical Thinking ANSWERS (41-50) -->
41. A nurse is planning the assignment for the day shift. The care team consists of an RN, an LPN/LVN, and a nursing assistant. Which of the following clients is most appropriate to assign to the nursing assistant?

a) a 50-year old obese client who needs assistance out of bed with a Hoyer lift
b) a 42-year old client who needs to be straight catheterized (in-and-out catheterization)
c) a 45-year old woman admitted for mastectomy and who is upset and tearful
d) a 62-year old client with an abdominal dressing and Montgomery straps

42. The nurse has delegated care of a client requiring nasopharyngeal suctioning to the LPN/LVN. Which of the following actions if performed by the LPN/LVN would require intervention by the nurse?

a) suction is applied as the catheter is inserted in the nares
b) the suction catheter is coiled as it is picked up from the sterile field
c) sterile gloves are used
d) the catheter is rotated slightly as it is inserted

43. The nurse has delegated care of a client who needs wrapping of an above the knee amputation stump to a LPN/LVN. Which of the following actions by the LPN/LVN would not require intervention by the nurse?

a) the stump is unwrapped for the bath and left unwrapped for 1 hour after
b) the stump is wrapped from proximal to distal
c) a diagonal figure of eight bandaging technique is used
d) care is taken to not flatten the skin at the end of the incision during wrapping

44. The nurse has delegated administration of 10am medications to an LPN/LVN. At 10:15am, the nurse notes none of the medications have been administer yet. Which is the best action for the nurse to take?

a) ask another LPN/LVN assigned to the unit to help administer medications
b) begin administering the medications
c) report he situation to the head nurse
d) ask the LPN/LVN to give the nurse a status report

45. A nurse on a pediatric unit is preparing the assignment for the evening shift. The unit employs unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP?

a) setting up Bryant's traction
b) completing the FACES pain scale for a child with sickle cell crisis
c) obtaining post-operative vital signs on a client status post-tonsillectomy
d) setting up an intravenous therapy pump

46. A new staff nurse is discussing with a nurse preceptor some of the ethical dilemmas related to delegation. Which resource is most appropriate for the nurse preceptor to direct the staff nurse to?

a) the Nursing Department Philosophy Statement
b) the National Council of State Board of Nurses
c) the Hospital Policy and Procedure Manual
d) the American Nurses Association's Code for Nurses

47. A nurse on a surgical unit is working with a team consisting of an LPN/LVN and a nursing assistant. Which of the following activities should be performed by the RN rather than delegated to the LPN/LVN or nursing assistant? Select all that apply

a) completing a pressure ulcer assessment form
b) setting up tracheal suctioning device
c) changing a dressing on an abdominal wound
d) documenting a client's level of pain on a pain scale
e) giving an oral pain medication to a client with prostate cancer
f) evaluating the response of a client to pain medication

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

 a) a client with a colostomy
b) a client with congestive heart failure
c) a client with decreased kidney function
d) a client receiving frequent wound irrigation

49. A nurse caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition?

a) lung congestion
b) decreased hematocrit
c) increased blood pressure
d) decreased central venous pressure (CVP)

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

a) the client taking diuretics
b) the client with renal failure
c) the client with ileostomy
d) the client who requires gastrointestinal suctioning



Go to the next page ---> NCLEX Preparation Course - Level of Cognitive Ability (51-60)

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Test Prep for Nursing Exam about Pediatric Nursing (51-55)

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51. A nurse is assessing an 8-week old (2 mos.) infant. Which of the following behaviors will the nurse expect to observe first in the infant's development?

a) holds head up when being pulled into a sitting position
b) turns from side to back
c) sits with minimal support
d) discriminates between strangers and familiar figures

52. A nurse in the pediatric clinic is interviewing a mother and a 6 year old child with asthma. Which statement if made by the mother should the nurse follow up on first?

a) my child would like to play on the softball team, but I am afraid to let him
b) my child has used three canisters of his inhaler this past month
c) my child is embarrassed to use his inhaler in front of schoolmates
d) I am concerned because my child has started to bite his nails and use cursatory words

53. A nurse is assessing a 3-year old child. Which of the following behaviors will the nurse expect to observe first in the child's cognitive development.

a) names the days of the week
b) knows primary colors
c) uses sentences well
d) think death is reversible

54. A nurse from medical-surgical unit is assigned to work on the pediatric unit. Which of the following clients is most appropriate for the charge nurse to assign to the float nurse?

a) an 8-year old client with asthma receiving inhaled medications
b) a 5-year old client admitted 24 hours ago for ingestion of household substance
c) a 10-year old client with a right femur fracture
d) a 6-year old client with malnutrition and bruises on the abdomen and buttocks

55. A nurse is teaching a client about the care of a female newborn. It is a priority to teach the client to notify the health care provider if which of the following is noted in the infant?

a) vomiting after feeding
b) more than four bowel movements per day
c) vaginal discharge
d) fever above 37.2C (100F)



ANSWERS AND RATIONALE

51) B
- a 2-month old infant is able to turn from side to back
Choice A describes a 3-4 month old infant
Choice C describes a 6 month old infant
Choice D describes an 8 month old infant

52) B
- excessive use of bronchodilator causes rebound effect, which is bronchoconstriction. It can also trigger asthmatic attack. This situation needs follow-up by the nurse.

53) D
- a 3-year old child thinks death as reversible. Choices A, B, and C are cognitive development among pre-school children.

54) A
- a nurse floated to a nursing unit should be assigned to care for a client with condition similar to her training and experience and those with stable condition. The medical-surgical unit nurse is competent to care for clients with asthma receiving inhaled medications.

55) D
- a newborn's temperature is normally 37C and below. Even slight elevation of temperature in a newborn, indicates acute infection. This situation needs to be reported to health care provider.
The nurse should teach the client to elevate the head of the newborn during feeding and to turn the newborn to the right side after feeding to prevent aspiration.

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NCLEX Review on Delegation and Prioritization Questions (21-25)

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NCLEX Review on Delegation and Prioritization Questions

21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if the nursing assistant:

a) advances the catheter 4 inches into the anal canal
b) hangs the enema bag 12 to 18 inches above the anus
c) lubricates 4 to 5 inches of the catheter tip
d) positions the client on the right side with head slightly elevated

22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following statements if made by the nurse regarding care of a client with crutches is most appropriate?

a) the client needs to ambulate with crutches and a two-point gait
b) ambulate the client without weight bearing every 4 hours the length of the hall and back
c) ask the client if she understands how to use a two-point gait, if not, please explain it to the client
d) make sure the client does not bend the elbows when using the crutches

23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse respond to first?

a) a client who received chemotherapy yesterday and is reporting nausea and vomiting
b) a client who was discharged two days ago with a urinary catheter after a transurethral prostactemomy and is reporting pink-tinged urine
c) a client with schizophrenia who says that the police has surrounded the house
d) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white secretions and became confused during the night

24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse attend to first?

a) a 3-year old child who cannot find her parents and is reporting a headache
b) a 48-year old male who has burns on both hands and reports severe pain
c) an 18-year old male who jumped from a second story window and is reporting severe arm pain
d) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing

25. A female college student reports to the student health center very distressed after waking up in a male student's restroom and not remembering what happened to the night before. The first action the nurse should take is:

a) obtain a rape kit
b) ask the client if she thinks she was raped
c) place the client in an examining room and leave her while she puts on a gown
d) provide a quiet, private area to use for initial assessment of the client




NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

21) D
- the appropriate position of the client during enema administration is left lateral position to facilitate flow of solution by gravity. Therefore, the action of the CNA in choices no. 4 needs to be corrected.

22) B
- when delegating task, the nurse should provide complete, concrete and specific directions.

23) D
- the situation indicates development of pulmonary edema in the client with chronic heart disease. This serious complication is a priority.

24) D
- burns on the face and neck involves obstruction of airway due to smoke inhalation. Airway is a priority.

25) D
- this situation indicates possible rape of the client. Providing psychosocial support and ensuring privacy for initial assessment of the client is most appropriate initial action.





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NCLEX Review about Cardiac Nursing (41-45)

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NCLEX Review about Cardiac Nursing

41. The nurse is completing the admission assessment on the client with chest pain. Which of the following statements by the client indicates the priority modifiable risk factor for coronary artery disease?

a) I have been told that I have a high cholesterol level
b) my father died of a heart attack at age 48
c) I have been under a lot of stress at work lately
d) I know I am overweight and have to do something about it

42. The client with chest pain was diagnosed with myocardial infarction and is now ready to be discharged. The nurse is reviewing discharge instructions. Which statement if made by the client indicates the highest priority teaching need?

a) I am going to try and cut down on smoking
b) from now on I am going to eat mainly fruits and vegetables
c) I plan to take up jogging when I go home
d) I plan to work half days for a while

43. A nurse is providing care to a client immediately after the insertion of a cardiac pacemaker. Which action is most important for the nurse to do first?

a) observe the incision site for signs of local infection
b) arrange for the client to have a post-insertion x-ray
c) monitor vital signs every 15 minutes until stable
d) encourage client to get out of bed with assistance

44. The home care nurse calls the wife of the client with chronic heart disease who is coughing frothy, white secretions and became confused during the night. Which question is most important for the nurse to ask?

a) did your husband eat breakfast this morning?
b) what did your husband do yesterday?
c) where did your husband sleep last night?
d) are your husband's ankles swollen?

45. The nurse is completing the admission assessment form on the client with chronic heart disease. Which of the following, if noted by the nurse, indicates a priority symptom of left-sided heart failure?

a) distended neck vein
b) edema of the lower extremities
c) weight gain of 10 pounds in the last month
d) crackles in the lungs




NCLEX Review about Cardiac Nursing:
ANSWERS AND RATIONALE

41) A
- high serum cholesterol level is one of the most common modifiable risk factor for coronary artery disease.

42) C
- walking is the best exercise for post-MI clients undergoing cardiac rehabilitation. Jogging may not be well-tolerated by the client. Therefore, choice C indicates knowledge deficit of the client and these requires further teaching.

43) C
- close monitoring of the client after insertion of cardiac pacemaker especially the vital signs is very essential. Changes in the vital signs indicate occurrence of complications.

44) C
- orthopnea, like sleeping in a couch indicates progressive heart failure like CHF (congestive heart failure) and pulmonary edema.

45) D
- left-sided congestive heart failure may lead to pulmonary edema. Signs and symptoms pertaining to the lungs are characteristic of left-sided congestive heart failure.
Choices A, B, and C are due to venous back-up which characterize right-sided congestive heart failure.




Go to the next page ---> NCLEX Review about Cardiac Nursing (46-50)  

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NCLEX Preparation Course - Critical Thinking Exercises VI (Answers 31-40)

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- the RN performs nursing process, including assessment. Choices A and D are for the CNA; choice B is for the LVN

32) A
- a client should not be grasped under the arm to pull him/her up in bed. This is to prevent injury in the axillary area and shoulder joints. Therefore, the situation needs intervention by the RN.

33) A
- giving information to the physician is appropriate nursing action. The RN is responsible for the LVN's actions.

34) B
- when delegating tasks, the RN should give concrete, specific, and clear directions. The RN should also explain the expected outcome of the task/action.


35) C
- the best source of information the nurse can refer to regarding which tasks are appropriate for which level of personnel in the Nurse Practice Act in the State the nurse is practicing.

36) A
- when injecting heparin subcutaneously, massaging the site should be avoided to prevent hematoma formation. Therefore, choice A needs intervention by the nurse.

37) B
- the LVN/LPN is allowed to do the task of suctioning tracheostomy. Clients with unstable condition should be assigned to the RN.

38) C
- the nurse should perform admission assessment. The RN should not delegate performing nursing process to the LVN/LPN.

39) A
- only tasks can be delegated by the RN, not accountability.

40) C
- turning the anti-embolism stockings inside out facilitates its application on the leg of the client.


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NCLEX Preparation Course - Critical Thinking Exercises VI (Questions 31-40)

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 Here are the Answers to NCLEX Preparation Course - Critical Thinking VI (31-40) -->

31. A nurse (RN) on a medical-surgical unit receives a new client admitted with abdominal pain. Which of the following activities should be performed by the RN rather than delegated to the LPN/LVN or nursing assistant?

a) preparing the client's chart
b) administering bedtime medications to the clients on the unit
c) completing the admission assessment for the new client
d) obtaining a clean-catch urine specimen from the client

32. A nurse is working with an LPN/LVN and a nursing assistant on a long-term care unit. The nurse observes the LPN/LVN and the nursing assistant moving a client up in bed to. The nurse will intervene if which of the following is observed?

a) the LPN/LVN and the nursing assistant grasp the client under the arms to pull up the bed
b) the client is asked to flex his knees and dig his heels in to help push up in bed
c) the bed is put in the high position prior to lifting the client
d) the side rails are lowered prior to lifting the client up in bed

33. A nurse working on a surgical unit is approached by a physician who asks if a client's consent form for surgery has been signed yet. The most appropriate response for the nurse is:

a) the LPN/LVN is caring for that client. I will check on whether the form is signed yet
b) I asked the other nurse on the floor to get that while I was at lunch. Please see that nurse about this
c) I have not had time to do that yet. I have been so busy today
d) I asked another nurse to get consent. I will check on whether it was done yet

34. An enema is ordered for a client as part of a bowel preparation for surgery. The nurse delegates the task to the LPN/LVN. Which of the following actions by the nurse is best?

a) write the task on the assignment sheet
b) explain the task and expected results to the LPN/LVN
c) explain to the client why the LPN/LVN will administer enema
d) if the LPN/LVN is too busy to give the enema, the nurse should give it

35. A new nurse is interested in learning more about how to appropriately delegate tasks to the LPN/LVNs and nursing assistants on the unit. The best source of information the nurse can refer to regarding which tasks are appropriate for which level of personnel is:

a) the American Nurses Association Code for Nurses
b) the hospital's Nursing Procedure Manual
c) The Nurse Practice Act in the State the nurse is practicing
d) a nursing management textbook

36. A nurse delegates medication administration for a group of clients to a LPN/LVN prepares to administer a subcutaneous (SQ) injection of heparin to a client. The nurse should intervene if the LPN/LVN:

a) rubs the injection site with alcohol before and after the injection
b) administer the heparin SQ injection in the left lower quadrant of the abdomen
c) does not aspirate after inserting the needle
d) gently withdraws the needle at the same angle it was inserted

37. A registered nurse on a medical surgical unit is preparing the assignment for the day shift. The RN is working with a licensed practical (vocational) nurse (LPN/LVN) and a nursing assistant. The RN most appropriately assigns which client to the LPN/LVN?

a) a newly admitted client with syncope
b) a client with tracheostomy needing suctioning
c) a client with cerebral palsy who needs assistance with feeding
d) a client with a below the knee amputation

38. A nurse on telemetry unit receives a new client admitted with atrial fibrillation. Which of the following activities should be performed by the RN rather than delegated to the LPN/LVN or nursing assistant?

a) attaching the leads of the cardiac monitor
b) obtaining an infusion pump for the client
c) completing the admission assessment for the client
d) obtaining a urinalysis specimen from the client

39. A nurse is working with a team consisting of an LPN/LVN and  nursing assistant. The nurse delegates medication administration to the LPN/LVN. According to the principles of delegation, the nurse knows that in delegating this task to the LPN/LVN, the nurse retains:

a) accountability
b) authority
c) responsibility
d) credibility

40. A nurse delegates application of anti-embolism stockings to an LPN/LVN. Which of the following actions, if observed by the nurse, would not require intervention?

a) rubs lotion on legs before applying stockings
b) applies stockings after client is assisted out of bed to a chair
c) turns the stocking inside out before applying
d) folds top of stockings over


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NCLEX Review on Delegation and Prioritization Questions (16-20)

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NCLEX Review on Delegation and Prioritization Questions

16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?

a) call for a social worker to meet with the family
b) check the child's blood pressure, then pulse, respiration, and temperature
c) administer pain medication
d) speak with the parents about how the fracture occurred

17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client should the nurse assess first?

a) a client scheduled for cardiac ultrasound this morning
b) a client with syncope being discharged today
c) a client with chronic bronchitis on nasal oxygen
d) a client with a diabetic foot ulcer that needs a dressing change

18.  A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first?

a) determine level of consciousness
b) push the call button for help
c) turn the client face up to assess
d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician

19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?

a) ask the other nurse if she needs any help
b) assess the client, and let the other nurse know what should be done
c) ask the client if he is satisfied with his care
d) contact the nursing supervisor to address the situation

20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of cerebral vascular disease. The caregiver learns that which immunization is a priority for the client?

a) hepatitis A vaccine
b) lyme disease vaccine
c) hepatitis B vaccine
d) pneumococccal vaccine





NCLEX Review on Delegation and Prioritization Questions:
ANSWERS AND RATIONALE

16) D
- in case of injury especially among children, it is very important that the nurse should first assess possible abuse. Abuse is one of the reporting responsibilities of the nurse.

17) C
- a client with problem of the airway should be attended first. ABC is a priority.

18) A
- assessing level of consciousness is the first action when dealing with a situation where the client might have had a fall or when preparing to do CPR (cardio-pulmonary resuscitation).

19) D
- the RN should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.

20) D
pneumococcal vaccine is a priority immunization for the elderly, especially those with chronic illness. It is administered every 5 years.




Go to the next page ---> NCLEX Review on Delegation and Prioritization Questions (21-25)  

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    NCLEX Review About The Aging Eye (11-15)

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    NCLEX Review About The Aging Eye

    11. Which of the following is an effective technique of communicating with a hearing impaired client?

    a) speak slowly in a low tone of voice
    b) speak slowly in a loud voice
    c) speak slowly and try to overemphasize words
    d) speak slowly and directly in front of the client

    12. Which of the following client statements indicates the need to postpone cataract surgery in the morning?

    a) this seasonal allergy should no be a problem
    b) the medications instilled into my eyes make my vision blurred
    c) I feel nervous with my operation tomorrow
    d) I have allergy to certain medications

    13. Which of the following is done when performing Weber test?

    a) place vibrating tuning fork in front of the opening of the ear
    b) place the vibrating tuning fork in the middle of the head
    c) place the vibrating tuning fork behind the ear
    d) irrigate the ear with cold water and observe movement of the eyes

    14. The client has been diagnosed to have Meniere's disease. Which of the following should be included when giving health teachings?

    a) limit carbohydrates and proteins in the diet
    b) limit salt intake
    c) limit fats in the diet
    d) drink a lot of fluids

    15. The nurse plans care for a client with acute glaucoma who reports severe pain in the eyes and rainbow colors (halos) around lights. Which action should the nurse take first?

    a) administer pain medication
    b) explain to the client that with reduction in intraocular pressure, pain and other symptoms will subside
    c) provide preoperative teachings to the client
    d) assess the client's visual status




    NCLEX Review About The Aging Eye:
    ANSWERS AND RATIONALE

    11) D
    - speaking slowly allows the client to understand the message. And speaking in fron of the client allows him to read the lip movement of the speaker. Avoid using loud voice pitch. High-pitched voice is more difficult to be understood by hearing-impaired client.

    12) A
    - seasonal allergy is characterized by sneezing and coughing. These may cause increase in intraocular pressure (IOP) and bleeding after eye surgery.

    13) B
    - describes weber test, which confirms presence of sensorineural hearing loss like Meniere's disease.

    14) B
    - meniere's disease is a disorder caused by increased endolymphatic pressure in the inner ear; characterized by vertigo, tinnitus, gradual hearing loss. Low sodium diet is indicated to prevent further accumulation of endolymphatic fluids.

    15) A
    - pain is the priority problem in a client with glaucoma. Loss of vision in glaucoma is irreversible.


    Go to the next page ---> NCLEX Review About The Aging Eye (16-20)  

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    NCLEX Review on Delegation and Prioritization Questions (11-15)

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    NCLEX Review on Delegation and Prioritization Questions

    11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?

    a) sit the client in a geriatric chair with an activity
    b) apply a vest restraint when the client is in a chair
    c) apply bilateral wrist restraints when the client is in bed
    d) have a staff member sit with the client at all times

    12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?

    a) perform venipuncture and start an IV line
    b) administer oxygen via nasal cannula
    c) administer morphine sulfate intravenously
    d) start lidocaine (xylocaine) infusion

    13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen first?

    a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breath
    b) a 16 year old male with ecchymosis, pain, and swelling of the right arm
    c) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder pain
    d) an 8 year old child who is crying hysterically and reports abdominal pain


    14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is:

    a) assess the child's airway and breathing
    b) call 911 and request an ambulance
    c) administer subcutaneous epinephrine
    d) remove the stinger from the foot

    15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse to take first is:

    a) tell the mother to position the child lying down on her side
    b) tell the mother to dial 911 and request an ambulance
    c) have the mother give the child a glass of milk
    d) instruct the mother on how to administer syrup of ipecac





    NCLEX Review on Delegation and Prioritization Questions:
    ANSWERS AND RATIONALE

    11) A
    promotion of safety and providing diversional activities are priority nursing care for confused elderly clients. Application of restraints should be the last resort. Having a staff member sit with the client at all times is not necessary, unless the client is at risk to injury.

    12) B
    - administration of oxygen is a priority nursing action in a client with chest pain. The primary reason for chest pain is inadequate myocardial oxygenation.

    13) A
    - the client with problem of the airway and who has unstable condition should be given highest priority. Priority ABC.

    14) A
    - the situation indicates that the child is having anaphylactic reaction. The first action by the nurse is to assess airway and breathing. Priority assessment is ABC.

    15) D
    - acetaminophen is non-corrosive. Therefore, inducing vomiting by administering syrup of ipecac is appropriate management in case of acetaminophen overdose or poisoning.




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      NCLEX Review about Digestive System Disorders 46-50

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      NCLEX Review about Digestive System Disorders

      46. A client has Sengstaken-Blakemore tube. The nurse, during change-of-shift report should remind the next shift nurse to:

      a) keep scissors at bedside
      b) avoid instilling fluid into the aspiration port
      c) keep tracheostomy tray at bedside
      d) deflate the balloon for 15 to 30 minutes every 2 hours

      47. The nurse is developing the plan of care for a client receiving continuous ambulatory peritoneal dialysis (CAPD). Which is the priority complication of CAPD to be addressed in the plan of care?

      a) bleeding
      b) pain
      c) outflow problems
      d) infection

      Situation: Bobby, a 13 year old is being seen in the emergency room for possible appendicitis.

      48. An important nursing action to perform when preparing Bobby for an appendectomy is to:

      a) administer saline enemas to cleanse the bowels
      b) apply heat to reduce pain
      c) measure abdominal girth
      d) continuously monitor pain

      49. Which of the following would indicate that Bobby's appendix has ruptured?

      a) diaphoresis
      b) anorexia
      c) pain at Mc Burney's point
      d) relief from pain

      50. A nurse is making a home health visit and finds the client experiencing right lower quadrant abdominal pain, which has decreased in intensity over the last day. The client also has a rigid abdomen and a temperature of 103.6 F. The nurse should intervene by:

      a) administering Tylenol (acetaminophen) for the elevated temperature
      b) advising the client to increase oral fluids
      c) asking the client when she last had a bowel movement
      d) notifying the physician




      NCLEX REVIEW ABOUT DIGESTIVE SYSTEM DISORDERS:
      ANSWERS AND RATIONALE

      46) A
      - the nurse should keep scissors readily available at bedside for a client with Sengstaken-Blakemore tube. The scissors will be used to cut the tube in case of airway obstruction due to rupture of the gastric balloon and the esophageal balloon goes up into the pharynx.

      47) D
      - the most common complication of CAPD is infection (peritonitis). This should be given highest priroty when planning the care of the patient undergoing CAPD.

      48) D
      - Appendicitis is inflammation of the vermiform appendix (4 inches long) which may lead to edema, necrosis, abscess and rupture, and peritonitis. It is common among teenagers and young adults between 10-30 years old. Higher incidence is observed among males and in societies with diet low in fiber and high in refined carbohydrates.

      Pain is closely monitored in appendicitis. In most cases, pain medication is not given until prior to surgery or until the diagnosis is confirmed to be able to closely monitor the progression of the disease. A sudden change in the character of pain may indicate rupture or bowel perforation.
      • Initially, appendicitis is manifested by acute and generalized pain of the abdomen that comes in waves.
      • During the following 4 hours, pain intensifies and localizes at the right lower quadrant pain at the Mc Burney's point between the anterior iliac crest and umbilicus.
      • The pain is aggravated by walking, moving and coughing
      • Rebound tenderness (relief of pain on palpation and sudden pain on release of pressure) occurs with abdominal rigidity causing the patient to guard the abdomen.
      • Patient tends to lie on back or side with knees bent to relieve pain as extension or internal rotation of the hip increases pain.
      Other manifestations of appendicitis include:
      • Anorexia, nausea and vomiting
      • Chills and fever
      • Leukocytosis - 10,000
      • elevated neutrophils count
      To prevent bowel perforation, it is important to avoid:
      • enemas
      • laxatives
      • applying heat over the abdomen
      • food and fluids per orem
      49) D

      50) D
      - the patient's manifestations indicate rupture of the appendix and peritonitis.






      Go to the next page ---> NCLEX Review about Digestive System Disorders 51-55  

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

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

      21) A
      - prothrombin time of 25 seconds is prolonged. Normal value is 11 to 16 seconds. Prolonged prothrombin time increases risk of bleeding during and after tonsillectomy. This should be reported to the physician.

      22) D
      - absence of breath sounds on one side of the chest indicates atelectasis. A client with problem of airway or oxygenation should be given highest priority. ABC is a priority.

      23) A
      - gingival hyperplasia indicates toxic reaction to anticonvulsant, specifically Dilantin. This needs follow-up. The other choices are normal findings.

      24) A
      - inform the relative on the nearest health service facility, in case a problem or emergency situation arises.

      25) B, C, D, F
      - comprise signs and symptoms of Cushing's reflex. The triad components of Cushing's reflex are blood pressure (systolic, diastolic, and pulse pressure), pulse rate and respiratory rate.

      26) A
      - silvery white scales characterize psoriasis
      Choice B - describes scabies
      Choice C - describes measles
      Choice D - describes herpes zoster

      27) B
      - mestinon, a cholinergic is best given 20 to 30 minutes before meals to prevent choking in a client with Myasthenia gravis.

      28) C
      - SIADH is hypersecretion of ADH. The client experiences excessive retention of water. Polyuria is not a manifestation of the disease. Polyuria is a characteristic of diabetes insipidus.

      29) A, C, D
      -these are nursing interventions after tonsillectomy. Bleeding should be prevented and monitored. It is manifested by frequent swallowing. Ice cream contains milk. This increases viscosity of the saliva that riggers clearing of the throat. Deep breathing is indicated. However, coughing is to be avoided to prevent bleeding.

      30) B
      - the LVN/LPN is allowed to do wound care and change of wound dressing. Choice A is a task to be done by RN; choices C and D are tasks to be done by the CNA.


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

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

      21.Prior to tonsillectomy in a child, which of the following laboratory results should be reported to the physician immediately?

      a) prothrombin time of 25 seconds
      b) hemoglobin of 10 mg/Dl
      c) WBC 0f 15,000/cu. mm
      d) platelet count of 200,000/cu. mm

      22. An emergency department has emergency drill. Which of the following should be given highest priority?

      a) a child with bloody face and with fixed, dilated pupils
      b) a patient with Glascow coma scale of 13
      c) a woman with fracture of legs and swelling
      d) a patient with no breath sounds on the affected side of the chest

      23. Which among the following patients needs follow-up care?

      a) a patient who has status epilepticus with gingival hyperplasia
      b) a patient taking rifampicin with red-orange urine
      c) a patient taking iron supplement with dark stools
      d) a patient taking digoxin whose apical rate decreased from 90 beats per minutes to 80 beats per minute

      24. A 76-year old man is to be discharged with his adult child and will stay with him. What will be the nurse's advice?

      a) inform the adult child on the nearest health service facility
      b) tell the patient that elder abuse is common
      c) advice for stay on a long-term healthcare facility
      d) inform the patient on availability of hospice care

      25. The client had head injury due to vehicular accident. He is experiencing Cushing's reflex. Which of the following would be manifested by the client? Select all that apply

      a) increased body temperature
      b) decreased respiratory rate
      c) increased systolic pressure
      d) decreased diastolic pressure
      e) restlessness
      f) widening of pulse pressure

      26. Which of the following is a characteristic lesion of Psoriasis?

      a) silvery white scales
      b) linear burrows
      c) maculo-papular lesions
      d) clusters of vesicles

      27. Which of the following interventions should be included in the care of the client with myasthenia gravis?

      a) start the client's meals with hot soup
      b) administer mestinon (pyridostigmine) before feeding
      c) place the client in isolation
      d) cover the eyes with eye patch

      28. Which of the following is not a manifestation of SIADH (Syndrome of Inappropriate ADH)?

      a) hyponatremia
      b) high specific gravity of urine
      c) polyuria
      d) hypertension

      29. Which of the following should be included in the nursing interventions of the client after tonsillectomy?

      a) assess for frequent swallowing
      b) include ice cream in the diet
      c) apply ice collar on the neck
      d) provide non-citrus, non-red, cold beverages
      e) encourage to do deep breathing and coughing exercises

      30. A registered nurse (RN) on a medical-surgical unit is preparing the assignment for the day shift. The RN is working with a licensed practical (vocational) nurse (LPN/LVN). and a nursing assistant. The RN most appropriately assigns which client to the LPN/LVN?

      a) a client who needs preoperative teaching for colectomy
      b) a client with a leg wound requiring a dressing change
      c) an elderly client who needs assistance with ambulation
      d) a client with a 24-hour urine collection process

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      NCLEX Review on Delegation and Prioritization Questions (6-10)

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      NCLEX Review on Delegation and Prioritization Questions

      6. A nurse is working in an emergency department and receives a client after a radiologic incident. Which task is a priority for the nurse to do first?

      a) decontaminate the client's clothing
      b) decontaminate an open wound on the client's thigh
      c) decontaminate the examination room the client is placed in
      d) save the client's vomitus for analysis by the radiation safety staff

      7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first?

      a) respiratory status
      b) level of consciousness
      c) level of pain
      d) reflexes and movement of extremities

      8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet?

      a) fiber
      b) broccoli
      c) yogurt
      d) simple carbohydrates

      9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent?

      a) pain
      b) wound infection
      c) depression
      d) thrombophlebitis


      10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first?

      a) administer pain medication
      b) administer IV fluids
      c) administer dopamine
      d) administer oxygen per nasal cannula




      NCLEX Review on Delegation and Prioritization Questions:
      ANSWERS AND RATIONALE

      6) B
      - decontaminating an open wound is the first priority when caring for a client after a radiologic incident. This minimizes absorption of radiation in the client's body.

      7) A
      - assessing respiratory status is the first priority when caring for a client in the post-anensthesia care unit. ABC is a priority.

      8) B
      - broccoli is gas forming. This should be avoided in clients experiencing flatulence.

      9) B
      - wound infection is the most common complication among obese clients who had undergone surgery. This is due to poor blood supply in the adipose tissues. Therefore, there is decreased oxygen supply and diminished supply of protective cells in the areas.

      10) D
      - promotion of adequate oxygenation is most vital to life. Therefore, this should be given highest priority by the nurse for a client with dyspnea, chest pain, and syncope.




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        NCLEX Review Questions on Cancer (31-35)

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        NCLEX Review Questions on Cancer

        31. Which of these findings in the breast of a patient who is suspected of having breast cancer would support the diagnosis?

        a) complaints of dull, achy, pain
        b) palpation of a mobile mass
        c) presence of an inverted nipple
        d) area of discoloration skin

        32. A nurse is caring for a client with an internal radiation implant. Which of the following instructions is appropriate?

        a) allow the client to go to the bathroom
        b) avoid creams and lotions
        c) visitors are allowed to stay in the room
        d) the client should remain in bed during the entire duration of treatment

        33. How often should a female who is above 40 years old, go for cancer detection examination?

        a) daily
        b) weekly
        c) monthly
        d) yearly


        34. The client is receiving internal radiation therapy. The nurse should

        a) remember to give the badge to the next-shift nurse
        b) maintain a 30-minute close contact with the patient in a shift
        c) wear gloves, mask and gown when entering the client's room
        d) instruct relatives no to visit the client during the entire duration of the treatment

        35. A nurse is assessing a client with metastatic breast cancer who reports nocturia, weakness, nausea and vomiting. The client's serum electrolytes include potassium 4.2 mEq/L, sodium 135 mEq/L, calcium 7.0 mEq/L, and magnesium 2.0 mEq/L. Based on the assessment findings, the priority action for the nurse is to:

        a) start client on fluid restriction
        b) administer calcium gluconate
        c) increase the client's IV fluids
        d) administer Allopurinol




        NCLEX Review Questions on Cancer:
        ANSWERS AND RATIONALE

        31) C
        - inversion of nipple is one of the manifestations of breast cancer. A cancerous lesion is non-mobile.

        32) D
        - the client with internal radiation implant should be on bed rest. This is to prevent dislodgment of the implant.

        33) D
        - cancer screening for females who are above 40 years of age should be yearly.

        34) A
        - dosimeter badge is used to measure amount of exposure to radiation. It should be endorsed to the next shift.

        35) C
        - nocturia, nausea and vomiting cause dehydration. Therefore, the correct nursing action is to increase the client's IV fluids.




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