Eye Health Questions (NCLEX 51-55)

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51. The nurse has an order to administer two opthalmic medications to the client who has undergone eye surgery. The nurse waits how many minutes after administering the first medication before giving the second?

a) 1 to 2
b) 3 to 5
c) 8 to 10
d) it is not necessary to wait; the second medication can be administered immediately

52. The nurse is assigned to care for a client who has just undergone cataract surgery. The nurse plans to instruct the client that which of the following activities is permitted in the postoperative period?

a) bending over
b) lifting objects
c) coughing exercises
d) watching television

53. During a routine visit to the physician's office for monitoring of diabetic control, an older client with diabetes mellitus complains to the nurse of vision changes. The client describes blurring of vision with difficulty in reading and with driving at night. Given the history, the nurse interprets that the client is probably developing:

a) cataracts
b) glaucoma
c) papilledema
d) detached retina

54. A client arrives at the emergency room with a chemical burn of the left eye. The nurse immediately:

a) applies a light bandage to the eye
b) performs an assessment on the client
c) applies a cold compress to the injured eye
d) flushes the eye continuously with a sterile solution

55. The home care nurse visits an older client with arthritis. The client complains of difficulty instilling glaucoma eye drops because of shaking hands caused by the arthritis. Which instruction should the nurse plans to provide to the client to alleviate this problem?

a) tilt the head back to instill the eye drops
b) lie down on a bed or sofa to instill the eye drops
c) a family member will have to instill the eye drops
d) keep the eye drops in the refrigerator so that they will thicken and be easier to instill







Eye Health Questions
Answers and Rationale

51) B

- The nurse waits 3 to 5 minutes between administration of the two separate ophthalmic medications. This allows for adequate ocular absorption of the medication and prevents the second medication from flushing out the first.

52) D

- The client is taught to avoid activities that raise intraocular pressure and could cause complications in the postoperative period. The client is also taught to avoid activities that cause rapid eye movements that are irritating in the presence of postoperative inflammation. For these reasons, the client is taught to avoid bending over, lifting heavy objects, straining, sneezing, coughing, making sudden movements, or reading. Watching television is permissible because the eye does not need to move rapidly with this activity, and it does not increase the intraocular pressure.

53) A

- Although the incidence of cataracts increases with age, the older client with diabetes mellitus is at greater risk for developing cataracts. The most frequent complaint is blurred vision that is not accompanied by pain. The client may also experience difficulty with reading, night driving, and glare. Options B, C, and D are not directly associated with this client's history or complaints.

54) D

- When the client has suffered a chemical burn of the eye, the nurse immediately flushes the site with a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water may be used. Performing an assessment may be helpful but is not the priority action. Applying compresses or bandages is incorrect, because they do not rid the eye of the damaging chemical. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid.

55) B

- Older clients with arthritis or shaking hands have difficulty instilling their own eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops. Tilting the head back can lead to a loss of balance. Eye drop regimens for glaucoma require accurate timing, and it is unreasonable to expect a family member to instill the eye drops. Additionally, this discourages client independence. Placing the eye drops in the refrigerator should not be done unless specifically prescribed.


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Endocrine NCLEX Questions (76-80)

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76. A client with a diagnosis of Cushing's syndrome is undergoing a dexamethasone suppression test. The nurse plans to implement which steps during this test?

a ) collect a 24-hour urine specimen to measure serum cortisol levels
b) administer 1 mg of dexamethasone orally at night and obtain serum cortisol levels the next morning
c) draw blood samples before and after exercise to evaluate the effect of exercise on serum cortisol levels
d) administer an injection of adrenocorticotropic hormone (ACTH) 30 minutes before drawing blood to measure serum cortisol levels


77. The nurse is caring for a client with type 1 diabetes mellitus. Which of the following laboratory results would indicate a potential complication associated with this disorder?

a) ketonuria
b) potassium: 4.2 mEq
c) blood glucose: 112 mg/dL
d) blood urea nitrogen (BUN): 18 mg/dL

78. Endocrine NCLEX Questions about the nurse who is employed in a diabetes mellitus clinic is caring for a client on insulin pump therapy. Which statement by the client indicates that a knowledge deficit exists regarding insulin pump therapy?

a) if my blood glucose is elevated, I can bolus myself with additional insulin as ordered
b) I'll need to check my blood glucose before meals in case I need a premeal insulin anymore
c) I still need to follow a diet and exercise plan even though I don't inject myself daily anymore
d) now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis ever happening again

79. A client with Grave's disease has exopthalmos and is experiencing photophobia. Which of the following nursing interventions would best assist the client with this problem?

a) obtain dark glasses for the client
b) lubricate the eyes with tap water every 2 to 4 hours
c) administer methimazole (Tapazole) every 8 hours around the clock
d) instruct the client to avoid straining or heavy lifting because this can increase eye pressure

80. The nurse is completing a health history on a client with diabetes mellitus who has been taking insulin for many years. At present the client states that he is experiencing periods of hypoglycemia followed by periods of hyperglycemia. The most likely cause for this occurrence is which of following?

a) eating snacks between meals
b) initiating the use of the insulin pump
c) injecting insulin at a site of lipodystrophy
d) adjusting insulin according to blood glucose levels





Endocrine NCLEX Questions
Answers and Rationale

76) B

- The dexamethasone suppression test is performed to evaluate the function of the adrenal cortex. The procedure for this test is to administer 1 mg of dexamethasone at 11:00 PM to suppress ACTH formation and then to obtain 8:00 AM serum cortisol levels on the following day.

77) A

- Ketonuria is an abnormal finding in the client with diabetes mellitus indicating ketosis. Ketosis is a metabolic effect from the lack of insulin on fat metabolism and occurs in type 1 diabetes mellitus. It is associated with the severe complication of diabetic ketoacidosis (hyperglycemia, ketosis, and acidosis). Options B, C, and D are all normal laboratory findings.

78) D

- Endocrine NCLEX Questions Rationale: Hypoglycemic reactions can occur if there is an error in calculating the insulin dose or if the pump malfunctions. Ketoacidosis can occur if too little insulin is used or if there is an increase in metabolic need. The pump does not have a built-in blood glucose monitoring feedback system, so the client is subject to the usual complications associated with insulin administration without the use of a pump. Options A, B, and C are accurate regarding the use of the insulin pump.

79) A

- Medical therapy for Graves' disease does not help alleviate the clinical manifestation of exophthalmos. Because photophobia (light intolerance) accompanies this disorder, dark glasses are helpful in alleviating the problem. Tap water, which is hypotonic, could actually cause more swelling around the eye because it could pull fluid into the interstitial space. In addition, the client is at risk for developing an eye infection because the solution is not sterile. Methimazole inhibits the synthesis of thyroid hormone and is used to treat hyperthyroidism but will not alleviate exophthalmos or photophobia. There is no need to avoid straining with exophthalmos.

80) C

- Lipodystrophy, specifically lipohypertrophy, involves swelling of the fat at the site of repeated injections. This can interfere with the absorption of insulin, resulting in erratic blood glucose levels. Because the client has been on insulin for many years, this is the most likely cause of poor control. Options A, B, and D are appropriate techniques to use in order to regulate blood glucose levels.


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Endocrine NCLEX Questions (71-75)

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71. A client undergoes a thyroidectomy and the nurse monitors the client for signs of damage to the parathyroid glands postoperatively. Which of the following findings would indicate damage to the parathyroid glands?

a) neck pain
b) hoarseness
c) respiratory distress
d) tingling around the mouth

72. A nurse is conducting a health history on a client with hyperparathyroidism. Which of the following questions asked of the client would elicit information about this condition?

a) do you have tremors in your hands?
b) are you experiencing pain in your joints?
c) have you had problems with diarrhea lately?
d) do you notice any swelling in your legs at night?

73. A client is admitted to the hospital in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares to administer which of the following medications as a primary initial treatment for this problem?

a) potassium
b) regular insulin
c) calcium gluconate
d) sodium bicarbonate

74. A client with Cushing's syndrome is being instructed by the nurse on follow-up care. Which statement by the client would indicate a need for further instructions?

a) I should avoid contact sports
b) I should check my ankles for swelling
c) I need to avoid foods high in potassium
d) I need to check my blood glucose regularly

75. A client with hyperaldosteronism is being treated with spironolactone (Aldactone)> Which of the following indicates to the nurse that the medication is effective?

a) a decrease in blood pressure
b) a decrease in sodium excretion
c) a decrease in body metabolism
d) a decrease in plasma potassium





Endocrine NCLEX Questions
Answers and Rationale

71) D

- The parathyroid glands can be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when parathyroid hormone (PTH) levels decrease. The nurse monitors for complaints of tingling around the mouth or of the toes or fingers and muscular twitching because these are signs of calcium deficiency. Additional later signs of hypocalcemia are positive Chvostek's and Trousseau's signs. Hoarseness and neck pain are expected findings postoperatively. Respiratory distress indicates a complication but is not a sign of damage to the parathyroid glands.

72) B

- Hyperparathyroidism causes an oversecretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain, and pathological fractures. Options A and C relate to assessment of hypoparathyroidism. Option D is unrelated to hyperparathyroidism.

73) B

- The primary treatment for any acid-base imbalance is the treatment of the underlying disorder that caused the problem. In this case, the underlying cause of the metabolic acidosis is anaerobic metabolism caused by the lack of the ability by the body to use circulating glucose. The administration of insulin corrects this problem. Potassium may be added to the treatment regimen if serum potassium levels indicate it is necessary. Options C and D would not be used in the treatment of this disorder.

74) C

- Hypokalemia is a common characteristic of Cushing's syndrome, and the client is instructed to consume foods high in potassium. Clients also experience activity intolerance, osteoporosis, and frequent bruising. Excess fluid volume results from water and sodium retention. Hyperglycemia is caused by an increased cortisol secretion.

75) A

- Aldactone antagonizes the effect of aldosterone and decreases circulating volume by inhibiting tubular reabsorption of sodium and water. Thus, it produces a decrease in blood pressure. It increases the excretion of sodium and water and increases potassium retention. It has no effect on body metabolism.


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Endocrine System Questions and Answers (66-70)

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66. The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addison's crisis?

a) prednisone (deltasone)orally
b) fludrocortisone (Florinef) subcutaneously
c) spironolactone (Aldactone) intramuscularly
d) methiprednisolone sodium succinate (Solu-Medrol) intravenously

67. The nurse is preparing a client with Graves' disease to receive radioactive iodine therapy. The nurse tells the client which of the following about the therapy?

a) following the initial dose, subsequent treatments must continue lifelong
b) the radioactive iodine is designed to destroy the entire thyroid gland with just one dose
c) it takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease
d) the high levels of radioactivity prohibit contact with family for 4 weeks after initial treatment

68. The nurse is preparing to care for a client returning from the operating room following a subtotal thyroidectomy. The nurse anticipates the need for which of the following items to be placed at the bedside?

a) hypothermia blanket
b) emergency tracheostomy kit
c) magnesium sulfate in a ready-to-inject vial
d) ampule of saturated solution of potassium iodide (SSKI)

69. The nurse is admitting a client with a diagnosis of myxedema to the hospital. The nurse performs which of the following that will provide data related to this diagnosis?

a) inspects facial features
b) auscultates lung sounds
c) percusses the thyroid gland
d) palpates the adrenal glands

70. A nurse is preparing postoperative discharge instructions for a client who had one adrenal gland removed. The nurse includes which of the following in the instructions?

a) the reason for maintaining a diabetic diet
b) teaching proper application of an ostomy pouch
c) instructions about early signs of a wound infection
d) the need for lifelong replacement of all adrenal hormones







Endocrine System Questions and Answers and Rationale

66) D

- A glucocorticoid preparation will be administered intravenously or intramuscularly in the immediate preoperative period to a client scheduled for an adrenalectomy. Methylprednisolone sodium succinate protects the client from developing acute adrenal insufficiency (Addison's crisis) that occurs as a result of the adrenalectomy. Aldactone is a potassium-sparing diuretic. Prednisone is an oral corticosteroid. Fludrocortisone is a mineralocorticoid.

67) C

- Following treatment with radioactive iodine therapy, a decrease in thyroid hormone level should be noted, which would help alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse needs to reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates. Occasionally, a client may require a second or third dose, but treatments are not lifelong.

68) B

- Respiratory distress can occur following thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem post-thyroidectomy. SSKI is typically administered preoperatively to block thyroid hormone synthesis and release, as well as to place the client in a euthyroid state.

69) A

- Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristic of myxedema. The assessment techniques in options B, C, and D will not reveal information related to the diagnosis of myxedema.

70) C

- A client who had a unilateral adrenalectomy will be placed on corticosteroids temporarily to avoid a cortisol deficiency. These medications will be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present. The client does not need to maintain a diabetic diet, and the client will not have an ostomy following this surgery.



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Endocrine System Questions and Answers (61-65)

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61. A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse places highest priority on which of the following nursing diagnoses developed for this client?

a) risk for infection
b) disturbed body image
c) ineffective health maintenance
d) risk for deficient fluid volume

62. A nurse is caring for a client with a diagnosis of Cushing's syndrome. The nurse plans which of these measures to prevent complications from this medical condition?

a) monitoring glucose level
b) encouraging daily jogging
c) monitoring epinephrine levels
d) encouraging visits form friends

63. A nurse notes on the cardiac monitor that a client with aldosteronism is experiencing a dysrhythmia. The nurse immediately assesses the client's:

a) peripheral pulses
b) intake and output
c) superficial reflexes
d) plasma potassium level

64. A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which of the following that is most likely to occur in this client?

a) hypovolemia
b) hypoglycemia
c) mood disturbances
d) deficient fluid volume

65. The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor that is producing excessive aldosterone (primary hyperaldosteronism). The nurse appropriately tells the client which of the following?

a) you will need to wear an abdominal binder after surgery
b) you will most likely need to undergo chemotherapy after surgery
c) you will need to take hormone replacements for the rest of your life
d) you will not require any special long-term treatment after surgery






Endocrine System Questions and Answers and Rationale

61) A

- The client with a stab wound has a break in the body's first line of defense against infection. The client with Cushing's disease is at great risk for infection caused by excess cortisol secretion, subsequent impaired antibody function, and decreased proliferation of lymphocytes. The client may also have an Ineffective health maintenance and Disturbed body image, but these are not the highest priority at this time. The client would be at risk for Excess fluid volume, not Deficient fluid volume, with Cushing's disease.

62) A

- In the client with Cushing's syndrome, increased levels of glucocorticoids can result in hyperglycemia and signs and symptoms of diabetes mellitus. Epinephrine levels are not affected. Clients experience activity intolerance related to muscle weakness and fatigue, therefore option B is incorrect. Visitors should be limited because of the client's impaired immune response.

63) D

- Aldosteronism can lead to hypokalemia, which in turn can cause life-threatening dysrhythmias. Options A, B, and C are not immediate priorities for this client.

64) C

- When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention, producing edema and hypertension.

65) C

- The major cause of primary hyperaldosteronism is an aldosterone-secreting tumor called an aldosteronoma. Surgery is the treatment of choice. Clients undergoing a bilateral adrenalectomy will need permanent replacement of adrenal hormones. Options A, B, and D are inaccurate.



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Endocrine System Questions and Answers (56-60)

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56. A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order?

a) maintain the endotracheal tube for 36 hours
b) take a rectal temperature only until discharge
c) ensure that intravenous calcium preparations are available
d) place the client in a flat position with the head and neck immobilized

57. While a client with myxedema is being admitted to the hospital, the client reports having experienced a lack of energy, cold intolerance, and puffiness around the eyes and face. The nurse knows that these symptoms are caused by a lack of production of which hormone(s)

a) luteinizing hormone (LH)
b) adrenocorticotropic hormone (ACTH)
c) triiodothyronine (T3) and thyroxine (T4)
d) prolactin (PRL) and growth hormone (GH)

58. A 33-years old female is admitted to the hospital with a suspected diagnosis of grave's disease. Which symptom related to the client's menstrual cycle would the client likely report?

a) amenorrhea
b) metrorrhagia
c) menorrhagia
d) dysmenorrha

59. A client with diabetes mellitus has a blood glucose level of 644 mg/dL. The nurse interprets that this client is most at risk of developing which type of acid-base imbalance?

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

60. The home care nurse is developing a plan of care for an older client with diabetes mellitus who has gastroenteritis. In order to maintain food and fluid intake to prevent dehydration, the nurse plans to:

a) offer water only until the client is able to tolerate solid foods
b) withhold all fluids until vomiting has ceased for at least 4 hours
c) encourage the client to take 8 to 12 ounces of fluid every hour while awake
d) maintain a clear liquid diet for at least 5 days before advancing to solids to allow inflammation of the bowel to dissipate






Endocrine System Questions and Answers Rationale

56) C

- Hypocalcemia is a potentially life-threatening complication following parathyroidectomy, and the nurse should ensure that intravenous calcium preparations are readily available. Semi-Fowler's position is the position of choice to assist in lung expansion and prevent edema. Rectal temperatures are not required. Tympanic temperatures can be taken. The client will not necessarily have an endotracheal tube.

57) C

- Although all of these hormones originate from the anterior pituitary, only T3 and T4 are associated with the client's symptoms. Myxedema results from inadequate thyroid hormone levels (T3 and T4). Low levels of thyroid hormone result in an overall decrease in the basal metabolic rate, affecting virtually every body system and leading to weakness, fatigue, and a decrease in heat production. A decrease in LH results in the loss of secondary sex characteristics. A decrease in ACTH is seen in Addison's disease. PRL stimulates breast milk production by the mammary glands, and GH affects bone and soft tissue by promoting growth through protein anabolism and lipolysis.

58) A

- Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Dysmenorrhea, metrorrhagia, and menorrhagia are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.

59) A

- Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options B, C, and D are incorrect.

60) C

- The client should be offered liquids containing both glucose and electrolytes. Small amounts of fluid may be tolerated, even when vomiting is present. The diet should be advanced as tolerated and include a minimum of 100 to 150 grams of carbohydrates daily. Offering water only and maintaining liquids for 5 days will not prevent dehydration but may promote it in this client.


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Heart Failure NCLEX Questions 71-75

Welcome to Heart Failure NCLEX Questions. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :

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71. The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. The nurse should use which of the following methods to cover the dressing?

a) apply a kerlix roll and tape it to the skin
b) apply a large, soft pad, and tape it to the skin
c) apply small Montgomery straps and tie the edges together
d) apply a Kling roll and tape the edge of the roll onto the bandage

72. A client develops bilateral wheezes, crackles from bases to apices, orthopnea, and tachypnea, and the nurse notes the presence of +2 pitting edema. The nurse suspects pulmonary edema and notifies the physician. While awaiting the physician's arrival, the nurse avoids which action?

a) elevating the client's legs
b) preparing to administer IV morphine sulfate
c) preparing to administer IV furosemide (Lasix)
d) placing the client in the high Fowler's position

73. Heart Failure NCLEX Questions about the nurse who is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that the:

a) procedure is performed in the operating room
b) initial catheter insertion is quite painful; after that, there is little or no pain
c) client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard x-ray table for about 4 hours
d) client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations


74. A nurse admits a client with myocardial infarction (MI) to the coronary care unit (CCU). The nurse plans to do which of the following in delivering care to this client?

a) begin thrombolytic therapy
b) place the client on continuous cardiac monitoring
c) infuse intravenous (IV) fluid at a rate of 150 ml per hour
d) administer oxygen at a rate of 6 liters per minute by nasal cannula

75. The nurse is analyzing an ECG rhythm strip on an assigned client. The nurse notes that there are three small boxes from the beginning of the "P" wave to the "R" wave. The nurse records that the client's PR interval is:

a) 0.12 second
b) 0.20 second
c) 0.24 second
d) 0.40 second





Heart Failure NCLEX Questions
Answers and Rationale

71) D

- With an arterial leg ulcer, the nurse applies tape only to the bandage. Tape is never used directly on the skin because it could cause further tissue damage. For the same reason, Montgomery straps could not be applied to the skin (although these are generally intended for use on abdominal wounds, anyway). Standard dressing technique includes the use of Kling rolls on circumferential dressings.

72) A

- Elevating the client's legs would rapidly increase venous return to the right side of the heart and worsen the client's condition. The feet should be in the horizontal position, or the client could dangle at the bedside if the client's condition permits. Anxiety causes an increase in the oxygen demands on the heart. Morphine sulfate reduces anxiety and causes peripheral vasodilation and is likely to be prescribed. Furosemide will be prescribed because of its diuretic action. A high Fowler's position increases the thoracic capacity, allowing for improved ventilation.

73) D

- Heart Failure NCLEX Questions Rationale: Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so there is little to no pain with catheter insertion. The X-ray table is hard and may be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.

74) B

- Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring, administering oxygen at a rate of 2 to 4 liters per minute unless otherwise ordered, and ensuring an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep vein open rate to prevent fluid overload and heart failure. Thrombolytic therapy may or may not be prescribed by the physician. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event.

75) A

- Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.


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Heart Failure NCLEX Questions 1-5

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Cardiac Nurse Education (66-70)

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66. The nurse is preparing to initiate an intravenous nitroglycerin drip on a client with acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside?

a) defibrillator
b) pulse oximeter
c) central venous pressure (CVP) tray
d) noninvasive blood pressure monitor

67. A client is in ventricular tachycardia and the physician orders intravenous (IV) lidocaine (xylocaine). The nurse plans to dilute the concentrated solution of lidocaine with:

a) lactated ringer's
b) normal saline 0.9%
c) 5% dextrose in water
d) normal saline 0.45%

68. A client who recently experienced a myocardial infarction is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). The nurse plans to teach the client that, during this procedure, a balloon-tipped catheter will:

a) inflate a meshlike device that will spring open
b) be used to compress the plaque against the coronary blood vessel wall
c) cut away the plaque from the coronary vessel wall using a cutting blade
d) be positioned in coronary artery to take pressure measurements in the vessel

69. A nurse is planning care for the client with heart failure. The nurse asks the dietary department to remove which item from all meal trays before delivering them to the client?

a) 1% milk
b) margarine
c) salt packets
d) decaffeinated tea


70. A client has just been admitted to the emergency department with chest pain. Serum enzyme levels are drawn, and the results indicate an elevated serum creatinine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with:

a) stable angina
b) unstable angina
c) prinzmetal's angina
d) new-onset myocardial infarction (MI)







Cardiac Nurse Education
Answers and Rationale

66) D

- Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.

67) C

- Lidocaine for IV administration is dispensed in concentrated and dilute formulations. The concentrated formulation must be diluted with 5% dextrose in water.

68) B

- In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option C describes coronary atherectomy, option A describes placement of a coronary stent, and option D describes part of the process used in cardiac catheterization.

69) C

- Sodium restriction reduces water retention and improves cardiac efficiency. A standard dietary modification for the client with heart failure is sodium restriction.

70) D

- Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise 3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Therefore, the client's results are compatible with new-onset MI. Options A, B, and C all refer to angina. These levels would not be elevated in angina.



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Cardiac Nurse Education (61-65)

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61. The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The appropriate nursing action is to:

a) prepare for defibrillation
b) continue to monitor the rhythm
c) notify the physician immediately
d) prepare to administer lidocaine hydrochloride (xylocaine)

62. The nurse is caring for a client who has been transferred to the surgical unit after having a pelvic exenteration. During the postoperative period, the client complains of pain in the calf area. What action should the nurse take?

a) ask the client to walk and observe the gait
b) lightly massage the calf area to relieve the pain
c) check the calf area for temperature, color, and size
d) administer prn morphine as prescribed for postoperative pain

63. A client has developed atrial fibrillation and has a ventricular rate of 150 bpm. The nurse assesses the client for:

a) flat neck veins
b) nausea and vomiting
c) hypotension and dizziness
d) hypertension and headache

64. A 45 year old client is admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia noted on Holter monitoring. The client is scheduled for electrophysiology studies (EPS) the following morning. Which statement should the nurse include in a teaching plan for this client?

a) you will continue to take your medications until the morning of the test
b) you will be sedated during the procedure and will not remember what has happened
c) this test is a noninvasive method of determining the effectiveness of your medication
d) during the procedure, a special wire is used to increase the heart rate and produce the irregular beats that caused your signs and symptoms

65. A nurse is providing diet teaching to a client with congestive heart failure (CHF). The nurse tells the client to avoid which of the following?

a) sherbet
b) steak sauce
c) apple juice
d) leafy green vegetables






Cardiac Nurse Education
Answers and Rationale

61) B

- As an isolated occurrence, the PVC is not life threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the physician needs to be notified.

62) C

- The nurse monitors for postoperative complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options A and B could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client complaint is not the appropriate nursing action. Further assessment needs to take place.

63) C

- The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

64) D

- The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test in order to study the dysrhythmias without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.

65) B

- Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with CHF should monitor sodium intake.


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Musculoskeletal NCLEX Questions (76-80)

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76. The nurse is assessing the client who has just been measured and fitted for crutches. The nurse determines that the client's crutches are fitted correctly if:

a) the top of the crutch is even with the axilla
b) the elbow is straight when the hands is on the handgrip
c) the client's axilla is resting on the crutch pad during ambulation
d) the elbow is at a 30-degree angle when the hand is on the handgrip

77. The nurse is assigned to care for a client who is in traction. The nurse ensures a safe environment for the client by:

a) making sure that the knots are at the pulleys
b) checking the weights to be sure that they are off the floor
c) making sure that the head of the bed is kept at a 90-degree angle
d) monitor the weights to be sure that they are resting on a firm surface

78. Musculoskeletal NCLEX Questions  about a client with a possible rib fracture who has never had a chest x-ray. The nurse plans to tell the client which of the following about the procedure?

a) the x-ray stimulates a small amount of pain
b) the client will be asked to breathe in and out continuously during the x-ray
c) the x-ray technologist will stand next to the client during the x-ray
d) it is necessary to remove jewelry and any other metal objects from the chest area

79. The nurse has an order to get the client out of bed to a chair on the first postoperative day following total knee replacement. The nurse plans to do which of the following to protect the knee joint?

a) apply a compression dressing and put ice on the knee while sitting
b) obtain a walker to minimize weigh-bearing by the client on the affected leg
c) lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine
d) apply a knee immobilizer before getting the client up and elevate the client's surgical leg while sitting

80. The nurse is conducting a health screening clinic for osteoporosis. The nurse determines that which client seen in the clinic is at the greatest risk of developing this disorder?

a) a 25-year old female who jogs
b) a 36-year old male who has asthma
c) a 70-year old male who consumes excess alcohol
d) a sedentary 65-year old female who smokes cigarettes





Musculoskeletal NCLEX Questions
Answers and Rationale

76) D

- For optimal upper extremity leverage, the elbow should be at approximately 30 degrees of flexion when the hand is resting on the handgrip. The top of the crutch needs to be two to three finger widths lower than the axilla. When crutch walking, all weight needs to be on the hands to prevent nerve palsy from pressure on the axilla.

77) B

- To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

78) D

- Musculoskeletal NCLEX Questions Rationale - An x-ray is a photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. Any radiopaque objects such as jewelry or other metal must be removed from the chest area because they will interfere with the interpretation of the results. The x-ray is painless, and any discomfort would arise from repositioning a painful part for filming. The nurse may premedicate a client, if prescribed, who is at risk for pain. The client is asked to breathe in deeply and then hold the breath while the chest x-ray is taken. To minimize the risk of radiation exposure, the x-ray technologist stands in a separate area protected by a lead wall. The client also wears a lead shield over the reproductive organs.

79) D

- The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint to provide stability. The surgeon orders the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema. Ice is not used unless prescribed. A compression dressing should already be in place on the wound. A CPM machine is used only while the client is in bed.

80) D

- Risk factors for osteoporosis include being female, postmenopausal status, advanced age, low-calcium diet, excessive alcohol intake, sedentary lifestyle, and cigarette smoking. The long-term use of corticosteroids, anticonvulsants, and furosemide (Lasix) also increase the risk.


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Musculoskeletal NCLEX Questions (71-75)

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71. A client has sustained a closed fracture and has just has a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which has provided very little pain relief. The nurse interprets that this pain may be caused by:

a) infection under the cast
b) the anxiety of the client
c) impaired tissue perfusion
d) the newness of the fracture

72. The client with a fractured femur experiences sudden dyspnea. A set of arterial blood gases reveal the following: pH is 7.32, PaCO2 is 43, PaO2 is 58, and HCO3 is 20. Which of the following components of the ABG results supports the nurse's suspicion of fat embolus?

a) pH
b) PaO2
c) HCO3
d) PaCO2

73. The rehabilitation nurse is providing home care instruction for a client being discharged after above-the-knee amputation of the right lower limb with a fitted prosthesis. The nurse determines the client requires further teaching if the client makes which of the following statements?

a) I will elevate the residual limb on a pillow
b) I will change the residual limb sock everyday
c) I will check the residual limb for skin irritation daily
d) I will notify my prosthesis if my residual limb sock becomes stretched or ill-fitting

74. A client arrives at the clinic complaining of knee pain. On assessment the nurse notes that the knee area is swollen. The nurse interprets that the client's signs and symptoms likely indicate:

a) osteoporosis
b) a recent injury
c) rheumatoid arthritis
d) degenerative joint disease

75. A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other leg. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a:

a) strain
b) sprain
c) fracture
d) contusion






Musculoskeletal NCLEX Questions
Answers and Rationale

71) C

- Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved from these measures should be reported to the physician, because it may be caused by impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.

72) B

- A key feature of fat embolism is a significant degree of hypoxemia with a Pao2 often less than 60 mm Hg. Other features that distinguish fat embolism from pulmonary embolism are an elevated temperature and the presence of fat in the blood with fat embolus.

73) A

- Clients must avoid elevation of the residual limb to prevent flexion contractures of the right hip. Additionally, sitting in a chair should be limited to 1-hour intervals to avoid the same. If there is no contraindication, clients should lie in the prone position three to four times a day to promote hip extension. Limb socks should be removed daily, laundered in mild soap, and replaced with a clean sock. When the sock is removed, the residual limb should be inspected for erythema and excoriation. As the edema resolves, the residual limb shrinks and the sock may not fit properly, leading to skin irritation. The prosthetist should be notified of the ill-fitting sock.

74) B

- Pain and swelling are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative joint disease, osteoporosis, and rheumatoid arthritis may be accompanied by pain, but swelling may or may not be present.

75) C

- Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.



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NCLEX RN Questions: Musculoskeletal Injuries (66-70)

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66. A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse prepares to provide which type of wound care to the fasciotomy site?

a) dry sterile dressings
b) hydrocolloid dressings
c) wet sterile saline dressings
d) one-half strength betadine dressings

67. An older client admitted to the hospital with a hip fracture is placed in Buck's extension traction. The nurse plans to frequently monitor which specimen item?

a) temperature
b) mental state
c) neurovascular status
d) range of motion ability

68. Buck's extension traction is applied to an older client following a hip fracture. The nurse explains to the client that this type of traction is:

a) traction involving the use of a cast
b) skeletal traction involving the use of surgically inserted pins
c) circumferential traction involving the use of a belt around the body
d) skin traction involving the use of traction attached to the skin and soft tissues

69. A client has Buck's extension traction applied to the right leg. The nurse plans which of the following interventions to prevent complications from the device?

a) provide pin care once a shift
b) massage the skin of the right leg with lotion every 8 hours
c) inspect the skin on the right leg at least once every 8 hours
d) release the weights on the right leg for range of motion exercises daily

70. The nurse is caring for a client with a newly applied leg cast. The nurse prevents the development of compartment syndrome by:

a) elevating the limb and applying ice to the affected leg
b) elevating the limb and covering the limb with bath blankets
c) keeping the leg horizontal and applying ice to the affected leg
d) placing the leg in a slight dependent position and applying ice








NCLEX RN Questions:
Answers and Rationale

66) C

- The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with wet sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so there should be no reason to require Betadine. Additionally, Betadine can be irritating to normal tissues.

67) C

- The neurovascular status of the extremity of the client in Buck's extension traction must be assessed frequently. Older clients are especially at risk for neurovascular compromise because many older clients already have disorders that affect the peripheral vascular system. Although the client's temperature is monitored, it is not specific to the use of Buck's extension traction. Although clients in some types of traction do become depressed after a few days or weeks, Buck's extension traction is usually used preoperatively, which typically involves a few hours or 1 to 2 days, at the most. Range of motion of the involved leg is contraindicated in hip fractures.

68) D

- Buck's extension traction is a form of skin traction and involves the use of a belt or boot that is attached to the skin and soft tissues. The purpose of this type of traction is to decrease painful muscle spasms that accompany fractures. The weight that is used as a pulling force is limited (usually 5 to 10 pounds) to prevent injury to the skin. Options A, B, and C are incorrect descriptions.

69) C

Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.

70) A

- Compartment syndrome is prevented by controlling edema. This is achieved most optimally with the use of elevation and the application of ice. The use of bath blankets or a dependent or horizontal leg position will not prevent this syndrome.



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NCLEX RN Questions: Musculoskeletal Injuries (61-65)

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61. A nurse is performing pin site care on a client in skeletal traction. Which finding would the nurse expect to note when assessing the pin sites?

a) loose pin sites
b) clear drainage from the pin sites
c) purulent drainage from the pin sites
d) redness and swelling around the pin sites

62. A nurse is caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur. The nurse prepares to perform a complete neurovascular assessment of the affected extremity and plans to assess:

a) vital signs and bilateral lung sounds
b) warmth of the skin and the temperature in the affected extremity
c) pain level and for the presence of edema in the affected extremity
d) color, sensation, movement, capillary refill, and pulse of the affected extremity

63. A client in the emergency department has a cast applied. The client arrives at the nursing unit, and the nurse prepares to transfer the client into the bed by:

a) placing ice on top of the cast
b) supporting the cast with the fingertips only
c) asking the client to support the cast during transfer
d) using the palms of the hands and soft pillows to support the cast

64. A nurse is caring for a client who has been placed in Buck's extension traction. The nurse provides for countertraction to reduce shear and friction by:

a) using a footboard
b) providing an overhead trapeze
c) slightly elevating the foot of the bed
d) slightly elevating the head of the bed

65. The nurse is caring for a client who develops compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that:

a) A bone fragment has injured the nerve supply in the area
b) an injured artery causes impaired arterial perfusion through the compartment
c) bleeding and swelling cause increased pressure in an area that cannot expand
d) the fascia expands with injury, causing pressure on underlying nerves and muscles






NCLEX RN Questions
Answers and Rationale

61) B

- A small amount of clear drainage ("weeping") may be expected after cleaning and removing crusting around the pin sites. Redness and swelling around the pin sites and purulent drainage may be indicative of an infection. Pins should not be loose, and, if this is noted, the physician should be notified.

62) D

- A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity.

63) D

- The palms or the flat surface of the extended fingers should be used when moving a wet cast to prevent indentations. Pillows are used to support the curves of the cast to prevent cracking or flattening of the cast from the weight of the body. Half-full bags of ice may be placed next to the cast to prevent swelling, but this action would be performed after the client is placed in bed. Asking the client to support the cast during transfer is inappropriate.

64) C

- The part of the bed under an area in traction is usually elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. An overhead trapeze or footboard is not used to provide countertraction. Option C provides a force that opposes the traction force effectively without harming the client.

65) C

- Compartment syndrome is caused by bleeding and swelling within a compartment, which is lined by fascia that does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.



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NCLEX RN Questions about Musculoskeletal Injuries (56-60)

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56. A client with a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, the nurse provides which information to the client to prevent complications?

a) trim the rough edges of the cast after it is dry
b) weigh-bearing on the right leg is allowed once the cast feels dry
c) expect burning and tingling sensations under the cast for 3 to 4 days
d) keep the right ankle elevated above the heart level with pillows for 24 hours

57. An older adult female client with a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign or symptom that indicates a complication associated with crutch walking?

a) left leg discomfort
b) weak biceps brachii
c) triceps muscle spasms
d) forearm muscle weakness

58. A nurse is caring for a client with Buck's traction and is monitoring the client for complications of the traction. Which assessment finding indicates a complication?

a) weak pedal pulses
b) drainage at the pin sites
c) complaints of discomfort
d) warm toes with brisk capillary refill

59. A client has fallen and sustained a leg injury. Which question would the nurse ask the cleint to help determine if the injury caused a fracture?

a) is the pain a dull ache?
b) is the pain sharp and continuous?
c) does the discomfort feel like a cramp?
d) does the pain feel like the muscle was stretched?

60. The nurse is assessing the casted extremity of a client for signs of infection. Which of the following findings is indicative of infection?

a) dependent edema
b) diminished distal pulse
c) coolness and pallor of the skin
d) presence of a "hot spot" on the cast





NCLEX RN Questions:
Answers and Rationale

56) D

- Leg elevation is important to increase venous return and decrease edema, which can cause compartment syndrome, a major complication of fractures and casting. Weight-bearing on a fractured extremity is prescribed by the physician during follow-up examination, after radiographs are obtained. Additionally, a walking heel or cast shoe may be added to the cast if the client is allowed to bear weight and walk on the affected leg. Although the client may feel heat after the cast is applied, burning and/or tingling sensations indicate nerve damage or ischemia and are not expected. These complaints should be reported immediately. Option 1 is incorrect. The client and/or family may be taught how to "petal" the cast to prevent skin irritation and breakdown, but rough edges, if trimmed, can fall into the cast and cause a break in skin integrity.

57) D

- Forearm muscle weakness is a sign of radial nerve injury caused by crutch pressure on the axillae. When a client lacks upper body strength, especially in the flexor and extensor muscles of the arms, he or she frequently allows weight to rest on the axillae and on the crutch pads instead of using the arms for support while ambulating with crutches. Leg discomfort is expected as a result of the injury. Triceps muscle spasms may occur as a result of increased muscle use but is not a complication of crutch walking. Weak biceps brachii is a common physical assessment finding in older adults and is not a complication of crutch walking.

58) A

- Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction.

59) B

- Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Strains result from trauma to a muscle body or to the attachment of a tendon from overstretching or overextension. Muscle injury is often described as an aching or cramping pain, or soreness.

60) D

- Signs and symptoms of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of "hot spots," which are areas on the cast that are warmer than others. The physician should be notified if any of these occur.


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NCLEX RN Questions about Delegation and Prioritization Questions 101-105

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101. A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse (LPN) and a nursing assistant on the team and is planning the client assignments for the day. The RN appropriately assigns which of the following clients to the LPN?

a) a client who needs assistance with grooming
b) a client who needs frequent ambulation
c) a client who needs to be suctioned as needed (PRN)
d) a client who needs assistance with hygiene measures


102. A nurse is planning client assignments. Which of the following is the least appropriate assignment for the nursing assistant?

a) assisting a profoundly developmentally disabled child to eat lunch
b) obtaining frequent oral temperatures on a client
c) accompanying a 51-year old man, being discharged to home following a bowel resection
d) collecting a urine specimen from a 70-year old woman admitted 3 days ago

103. A nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first?

a) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift
b) a postoperative client preparing fro discharge
c) a client scheduled for a chest x-ray
d) a client requiring daily dressing changes

104. A nurse is planning the client assignments for the shift. Which of the following clients would the nurse appropriately assign to the nursing assistant?

a) a client requiring twice -daily dry dressing changes
b) a client requiring frequent ambulation with a walker
c) a client on a bowel management program requiring rectal suppositories and a daily enema
d) a client with diabetes mellitus requiring daily insulin and reinforcement of dietary measures

105. A client with a spinal cord injury develops a severe, pounding headache. The client is diaphoretic, hypertensive, and bradycardic and complains of nausea and nasal congestion. The nurse determines that the client is experiencing autonomic hyperreflexia (autonomic dysreflexia). Which action would the nurse take first?

a) notify the physician
b) document the findings
c) perform a rectal examination
d) place the client in a sitting position






NCLEX RN:
Answers and Rationale

101) C

- When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Option C can be assigned to the LPN because this staff member can perform certain invasive procedures. Noninvasive interventions can be assigned to a nursing assistant. These include the tasks identified in options A, B, and D.

102) A

- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating and therefore a higher potential for complications such as choking and aspiration. The remaining three options include no data indicating that these tasks carry any unforeseen risk.

103) A

- Airway is always a high priority, so the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options B, C, and D would be an intermediate priority.

104) B

- Assignment of tasks needs to be implemented on the basis of the job description of the nursing assistant, the level of clinical competence, and state law. Options A, C, and D involve care that requires the skill of a licensed nurse. Although a nursing assistant may be trained to administer an enema (depending on state practice acts and agency policy), a rectal suppository needs to be administered by a licensed nurse. Option B is the most appropriate assignment for the nursing assistant.

105) D

- Autonomic hyperreflexia is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are innocuous in normal individuals. It occurs only after spinal shock has resolved. A number of stimuli may trigger this response, including a distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction), or stimulation of the skin. When autonomic hyperreflexia occurs, the client is immediately placed in a sitting position to lower the blood pressure. The nurse would then perform a rapid assessment to identify and alleviate the cause. The client's bladder is emptied immediately via a urinary catheter, the rectum is checked for the presence of a fecal mass, and the skin is examined for areas of pressure, irritation, or broken skin. The physician is notified, and the nurse documents the occurrence and the actions taken.


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NCLEX Review about Ear Infection 46-50

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46. A nurse is caring for a hospitalized client with an acute attack of Meniere's disease. The client verbalizes concern because the client has experienced a hearing loss as a result of the attack. Which of the following responses would the nurse make to the client regarding the hearing loss?

a) it will take several weeks before the hearing returns
b) the hearing loss will fluctuate for a period of 1 week
c) the attack leaves a hearing loss in the involved ear
d) the hearing will return to normal

47. A nurse is reviewing the physician's orders on a client admitted to the hospital with a diagnosis of an acute attack of Meniere's disease. Which of the following orders, if noted on the client's chart, would the nurse question?

a) the administration of a sedative
b) the administration of an antihistamine
c) the administration of vasoconstrictor
d) bedrest

48. A nurse is providing discharge instructions to the client who was hospitalized for an acute attack of Meniere's disease. Which of the following statements, if made by the client, indicates a need for further instructions?

a) I need to take the diuretics to decrease the fluid in the ear
b) I need to take antihistamine as prescribed
c) I need to take a vasodilator
d) it is not necessary to restrict salt in my diet

49. A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse prepares instructions for the client regarding home care after the procedure. Which statement by the client indicates a need for further instructions?

a) I need water out of the ear canal for at least 3 weeks
b) I need to avoid air travel for at least 1 year
c) I need to notify the physician if I experience any persistent dizziness
d) I need to avoid bending and lifting heavy objects for at least 3 weeks

50. A community health nurse is conducting a health-screening clinic and is scheduled to perform hearing tests on the clients who attend the screening session. Several nurses have volunteered to assist with the screening clinic. The community health nurse instructs the nurses to perform a voice test to assess hearing in the clients and tells the nurses to do which of the following?

a) with back to the client, whisper a statement, and determine if the client can clearly repeat it
b) face the client, and whisper a statement while the client blocks both ears
c) stand 4 feet away from the client when talking to the client, and determine if the client can hear at this distance
d) quietly whisper a statement, and ask the client to repeat it to determine the hearing ability





NCLEX Review
Answers and Rationale

46) C
- After the acute phase, remission occurs, but symptoms of the disease will recur with two or three acute attacks occurring per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss, varying from slight to complete. It takes several weeks before all symptoms subside after an attack, leaving a loss of hearing in the involved ear. Options A, B, and D are incorrect.

47) C

- Medical interventions during the acute phase of Meniere's disease include using atropine or diazepam (Valium) to decrease the autonomic nervous system function. Diphenhydramine (Benadryl) may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bedrest during the acute attack, and when allowed to be out of bed, the client will need assistance with walking, sitting, or standing.

48) D
- Management during remission includes the use of diuretics to decrease the fluid and thereby decrease pressure in the endolymph. Antihistamines, vasodilators, and diuretics may be prescribed for the client. A low-salt diet is prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client's hearing, and careful medical management helps achieve this in most clients with Ménière's disease.

49) B

- After stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client also is instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If sudden hearing loss, fever, or severe persistent vertigo or dizziness develops, the physician should be notified.

50) D

- The examiner should stand 1 to 2 feet away from the client and ask the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Options A, B, and C are incorrect.


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NCLEX Review about Ear Infection 1-5

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NCLEX Review about Ear Infection 41-45

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41. A nurse is preparing a plan of care for a client being admitted to the hospital with exacerbation of Meniere's disease. Which of the following would the nurse include in the plan of care?

a) increase fluid intake to 3000 ml a day
b) tell the client to avoid moving the head suddenly
c) maintain a quiet environment, and allow the client to read and watch TV
d) increase foods high in sodium in the diet

42. A nurse is performing an assessment of a client suspected of having mastoiditis. Which finding would the nurse expect to note if this disorder is present?

a) an elevated temperature
b) a red, dull, thick, and immobile tympanic membrane
c) a clear tympanic membrane
d) a transparent tympanic membrane

43. A nurse is performing an admission assessment of a client with a disorder involving the inner ear. Which of the following questions will the nurse ask the client to determine if the common symptom of this type of ear disorder is present?

a) do you have any hearing loss?
b) do you have any itching around your ear?
c) do you have any ringing in the ears?
d) do you have any pain in the ear?

44. A new nursing graduate has been hired by the health care clinic to assist in conducting hearing tests in a local neighborhood. The clinic nurse is observing the nursing graduate perform a voice test to assess hearing in a client. Which of the following observations indicates that the graduate is performing the procedure correctly?

a) start 10 feet away from the client to determine if the client can hear clearly
b) asks the cleint to block one ear, quietly whispers a statement, and asks the client to repeat it
c) whispers a statement with the back facing the client
d) asks the client to block the ears, faces the client, verbalizes a statement, and asks the client to repeat the statement

45. A clinic nurse receives a telephone call form a client who states that an insect has somehow flown into her ear and that a buzzing sound can be heard. The client asks the nurse how to remove the insect. Which of the following instructions should the nurse initially provide to the client?

a) have her spouse irrigate ear to kill the insect
b) use a flashlight to try to coax the insect out of the ear
c) instill antibiotic eardrops if they are available
d) get into the shower and allow the ear to run into the ear to flush out the insect








NCLEX Review:
Answers and Rationale

41) B

Exacerbation of Ménière's disease is characterized by severe vertigo. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects.

42) B

- Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

43) C

- Tinnitus is the most common complaint of clients with otological disorders, especially those involving the inner ear. This symptom can range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client's thinking process and attention span. The client may experience some pain or hearing loss, depending on the disorder, but these are not the most common symptoms. Itching around the ear may be associated with a disorder other than an inner ear disorder.

44) B

- In a voice test, the nurse stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Options A, C, and D are incorrect procedures.

45) B

- Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed with ear forceps in the emergency department. It is not appropriate to ask the spouse to irrigate the ear. Suggesting the use of antibiotics is inappropriate. Option D is also inappropriate and may cause additional discomfort.



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NCLEX Review about Ear Infection 1-5


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NCLEX Review about Ear Infection 46-50

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