NCLEX Pharmacology Practice Questions (96-100)

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96. A client with schizophrenia tells the nurse, "I stopped taking my chlorpromazine (Thorazine) because of the way it made me feel." Which side effect is the nurse likely to note during further assessment of the client's complaint?

a) drowsiness
b) nervousness
c) hard tremors
d) increased urination

97. A nurse is caring for a client diagnosed with a skin infection who is receiving tobramycin sulfate (Nebcin) intravenously every 8 hours. Which of the following would indicate to the nurse that the client is experiencing an adverse reaction related to the medication?

a) a total bilirubin of 0.5 mg/dL
b) a sedimentation rate of 15 mm/hr
c) a blood urea nitrogen (BUN) of 30 mg/dL
d) a white blood cell count (WBC) of 6000 cells/mm3

98. A client has been taking an anti-hypertensive for approximately 2 months. A home care nurse monitoring  the effects of therapy determines that drug tolerance has developed if which of the following are noted in the client?

a) decrease in weight
b) output greater than intake
c) decrease in blood pressure
d) gradual rise in blood pressure

99. A nurse has an order to administer hydroxyzine (Vistaril) to a client by the intramuscular route. Before administering the medication, the nurse tells the client that:

a)  excessive salivation is a side effect
b) there will be some pain at the injection site
c) there will be relief from nausea within 5 minutes
d) the client will have increased alertness for about 2 hours

100. A nurse is preparing to administering diazepam (Valium) by the intravenous (IV) route to a client who is having a seizure. The nurse plans to:

a) administer the prescribed dose over at least 60 minutes
b) dilute the prescribed dose in 50 ml of 5% dextrose in water
c) administer the prescribed by IV push directly into the vein
d) mix the prescribed dose into the existing IV of 5% dextrose in normal saline






NCLEX Pharmacology Practice Questions
Answers and Rationale

96) A
- Side effects of chlorpromazine can include hypotension, dizziness and fainting especially with parenteral use, drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, nasal congestion, peripheral edema, and urinary retention. Options B, C, and D are not side effects of chlorpromazine.

97) C
- Adverse reactions or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances. A normal WBC is 4500 to 11,000 cells/mm3. The normal sedimentation rate is 0 to 30 mm/hour. The normal total bilirubin level is less than 1.5 mg/dL. The normal BUN is 5 to 20 mg/dL.

98) D
- Drug tolerance can develop in a client taking an antihypertensive, which is evident by rising blood pressure levels. The physician should be notified, who may then increase the medication dosage or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. This would also warrant adding a diuretic to the course of therapy.

99) B
- Hydroxyzine is an antiemetic and sedative/hypnotic that may be used in conjunction with opioid analgesics for added effect. The injection can be extremely painful. Medications administered by the intramuscular route generally take 20 to 30 minutes to become effective. Hydroxyzine causes dry mouth and drowsiness as side effects.

100) C
- Intravenous diazepam is given by IV push directly into a large vein (reduces the risk of thrombophlebitis), at a rate no greater than 1 mg per minute. It should not be mixed with other medications or solutions and can be diluted only with normal saline.


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NCLEX Pharmacology Practice Questions (101-105)

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NCLEX Pharmacology Practice Questions (91-95)

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91. A client with myasthenia gravis is admitted to the hospital, and the nursing history reveals that the client is taking pyridostigmine (Mestinon). The nurse assesses the client for side effects of the medication and asks the client about the presence of:

a) mouth ulcers
b) muscle cramps
c) feelings of depression
d) unexplained weight gain

92. A nurse is performing an assessment on a client with a diagnosis of chronic angina pectoris who is receiving sotalol (Betapace) 80 mg orally daily. Which assessment finding indicates that the client is experiencing a side effect of the medication?

a) dry mouth
b) palpitations
c) diaphoresis
d) difficulty swallowing

93. A nurse is caring for a client who had an allogenic liver transplant and is receiving tacrolimus (Prograf) daily. Which finding indicates to the nurse that the client is experiencing an adverse reaction to the medication?

a) photophobia
b) hypotension
c) profuse sweating
d) decrease in urine output

94. A nurse is caring for a client who is receiving cyclosporine (Gengraf). Which of the following indicates to the nurse that the client is experiencing an adverse reaction to the medication?

a) acne
b) sweating
c) joint pain
d) hyperkalemia

95. A nurse is caring for a client with hypertension receiving torsemide (Demadex) 5 mg orally daily. Which of the following would indicate to the nurse that the client might be experiencing an adverse reaction related to the medication?

a) a chloride level of 98 mEq/L
b) a sodium level of 135 mEq?L
c) a potassium level of 3.1 mEq/L
d) a blood urea nitrogen (BUN) of 15 mg/dL






NCLEX Pharmacology Practice Questions
Answers and Rationale

91) B
- Mestinon is an acetylcholinesterase inhibitor. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors. Options A, C, and D are not associated with this medication.

92) B
-  Sotalol is a beta-adrenergic blocking agent. Side effects include bradycardia, palpitations, an irregular heartbeat, difficulty breathing, signs of congestive heart failure, and cold hands and feet. Gastrointestinal disturbances, anxiety and nervousness, and unusual tiredness and weakness can also occur. Options A, C, and D are not side effects of this medication.

93) D
- Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output.

94) D
- Cyclosporine is an immunosuppressant medication used in the prophylaxis of organ rejection. Adverse effects include nephrotoxicity, infection, hypertension, tremor, and hirsutism. Additionally, neurotoxicity, gastrointestinal effects, hyperkalemia, and hyperglycemia can occur. Options A, B, and C are not associated with this medication.

95) C
- Torsemide (Demadex) is a loop diuretic. The medication can produce acute, profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse. Option C is the only option that indicates an electrolyte depletion because the normal potassium level is 3.5 to 5.1 mEq/L. The normal sodium level is 135 to 145 mEq/L. The normal chloride level is 98 to 107 mEq/L. The normal blood BUN is 5 to 20 mg/dL.


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NCLEX Pharmacology Questions (86-90)

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86. A client with myasthenia gravis is admitted to the hospital, and the nursing history reveals that the client is taking pyridostigmine (Mestinon). The nurse assesses the client for side effects of the medication and asks the client about the presence of:

a) mouth ulcers
b) muscle cramps
c) feelings of depression
d) unexplained weight gain

87. A nurse is performing an assessment on a client with a diagnosis of chronic angina pectoris who is receiving sotalol (Betapace) 80 mg orally daily. Which assessment finding indicates that the client is experiencing a side effect of the medication?

a) dry mouth
b) palpitations
c) diaphoresis
d) difficulty swallowing

88. A nurse is caring for a client who had an allogenic liver transplant and is receiving tacrolimus (Prograf) daily. Which finding indicates to the nurse that the client is experiencing an adverse reaction to the medication?

a) photophobia
b) hypotension
c) profuse sweating
d) decrease in urine output

89. A nurse is caring for a client who is receiving cyclosporine (Gengraf). Which of the following indicates to the nurse that the client is experiencing an adverse reaction to the medication?

a) acne
b) sweating
c) joint pain
d) hyperkalemia

90. A nurse is caring for a client with hypertension receiving torsemide (Demadex) 5 mg orally daily. Which of the following would indicate to the nurse that the client might be experiencing an adverse reaction related to the medication?

a) a chloride level of 98mEq/L
b) a sodium level of 135 mEq/L
c) a potassium level of 3.1 mEq/L
d) a blood urea nitrogen (BUN) of 15 mg/dL






NCLEX Pharmacology Questions
Answers and Rationale

86) B
- Mestinon is an acetylcholinesterase inhibitor. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors. Options A, C, and D are not associated with this medication.

87) B
- Sotalol is a beta-adrenergic blocking agent. Side effects include bradycardia, palpitations, an irregular heartbeat, difficulty breathing, signs of congestive heart failure, and cold hands and feet. Gastrointestinal disturbances, anxiety and nervousness, and unusual tiredness and weakness can also occur. Options A, C, and D are not side effects of this medication.

88) D
- Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients receiving allogenic liver transplants. Frequent side effects include headache, tremor, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion. Nephrotoxicity is characterized by an increasing serum creatinine level and a decrease in urine output.

89) D
- Cyclosporine is an immunosuppressant medication used in the prophylaxis of organ rejection. Adverse effects include nephrotoxicity, infection, hypertension, tremor, and hirsutism. Additionally, neurotoxicity, gastrointestinal effects, hyperkalemia, and hyperglycemia can occur. Options A, B, and C are not associated with this medication.

90) C
- Torsemide (Demadex) is a loop diuretic. The medication can produce acute, profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse. Option 3 is the only option that indicates an electrolyte depletion because the normal potassium level is 3.5 to 5.1 mEq/L. The normal sodium level is 135 to 145 mEq/L. The normal chloride level is 98 to 107 mEq/L. The normal blood BUN is 5 to 20 mg/dL.



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Nursing Leadership Programs (46-50)

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46. A nurse is working in the emergency department of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. Which of the following actions by the nurse is contraindicated in the handling legal evidence?

a) initiate a chain of custody log
b) give clothing and wallet to the family
c) cut clothing along seams, avoiding bullet holes
d) place personal belongings in a labeled, sealed paper bag

47. A registered nurse (RN) is orienting a nursing assistant to the clinical nursing unit. The RN would intervene if the nursing assistant did which of the following during a routine handwashing procedure?

a) kept hands lower than elbows
b) dried from forearm down to fingers
c) washed continuously for 10 to 15 seconds
d) used 3 to 5 ml of soap from the dispenser

48. A registered nurse (RN) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. Following completion of the report, the RN intervenes if the staff member prepares to:

a) notify the nursing supervisor
b) ask the secretary to telephone the physician
c) document in the nurse's notes that an incident report was filed
d) forward incident report to the Continuous Quality Improvement Department

49. A physician visiting a client on the nursing unit is paged and notified that the monthly physician's breakfast meeting is about to start. The physician states to the nurse : "I'm in a hurry. Can you write an order t decrease the atenolol (Tenormin) to 25mg daily?" Which of the following is the appropriate nursing action?

a) write the order
b) call the nursing supervisor to write the order
c) inform the client of the change of medication
d) ask the physician to return to the nursing unit to write the order

50. A registered nurse suspects that a colleague is substance impaired and notes signs of alcohol intoxication in the colleague. The Nurse Practice Act requires the registered nurse do which of the following?

a) talk with the colleague
b) call the impaired nurse organization
c) report the information to a nursing supervisor
d) ask the colleague to go to the nurse's lounge to sleep for a while






Nursing Leadership Programs
Answers and Rationale

46) D

- Basic rules for handling evidence include limiting the number of people with access to the evidence, initiating a chain of custody log to track handling and movement of evidence, and carefully removing of clothing to avoid destroying evidence. This usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home.

47) B

- Proper handwashing procedure involves wetting the hands and wrists and keeping the hands lower than the forearms so that water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds, using rubbing and circular motions. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.

48) C

- Nurses are advised not to document the filing of an incident report in the nurses' notes for legal reasons. Incident reports inform the facility's administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also alert the facility's insurance company to a potential claim and the need for further investigation. Options A, B, and D are accurate interventions.

49) D

- Nurses are encouraged not to accept verbal orders from the physician because of the risks of error. The only exception to this may be in an emergency situation, and then the nurse must follow agency policy and procedure. Although the client will be informed of the change in the treatment plan, this is not the appropriate action at this time. The physician needs to write the new order. It is inappropriate to ask another individual other than the physician to write the order.

50) C

- Nurse Practice Acts require reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the Board of Nursing. Confronting the colleague may cause conflict. Asking the colleague to go to the nurses' lounge to sleep for awhile does not safeguard clients.




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Nursing Leadership NCLEX Questions (41-45)

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41. When assessing the client with the vest restraint (security device) at the beginning of day shift, which observation by the charge nurse would indicate that the nurse who placed the vest restraint on the client failed to follow safety guidelines?

a) a hitch was used to secure the restraint
b) the call light was placed within reach of the client
c) the restraint was applied tightly across the client's chest
d) the client's record indicates that the restraint will be released every 2 hours

42. A male client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the nursing assistant that:

a) enteric precautions should be instituted for the client
b) gloves and mask should be used when the in client's room
c) contact isolation should be initiated, because the diseases is highly contagious
d) standard precautions are sufficient, because the disease is transmitted sexually

43. A nursing assistant is caring for an older male client with cystits who has an indwelling urinary catheter. The registered nurse provides directions regarding urinary catheter care and ensures that the nursing assistant:

a) loops the tubing under the client's leg
b) places the tubing below the client's knee
c) uses soap and water to cleanse the perineal area
d) keeps the drainage bag above the level of the bladder

44. A nurse is planning care for a client with acute glomerulonephritis. The nurse instructs the nursing assistant to do which of the following in the care of the client?

a) ambulate the client frequently
b) monitor the temperature every 2 hours
c) encourage a diet that is high in protein
d) remove the water pitcher from the bedside

45. A nurse watches a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating doughnut next to the hemodialysis machine while talking with the client about the client's week. The first nurse should:

a) get a cup of coffee and join in on the conversation
b) determine whether or not the client would like a cup of coffee
c) admire the therapeutic relationship the second nurse has with the client
d) ask the second nurse to refrain from eating and drinking in the client area





Nursing Leadership NCLEX Questions:
Answers and Rationale

41) C

- A vest restraint should never be applied tightly because it could impair respirations. A hitch knot may be used on the client because it can easily be released in an emergency. The call light must always be within the client's reach in case the client needs assistance. The restraint needs to be released every 2 hours (or per agency policy) to provide movement.

42) D

- Chlamydia is a sexually transmitted disease. Caregivers cannot acquire the disease during administration of care, and standard precautions are the only measure that needs to be used.

43) C

- Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and, for the same reason, the drainage tubing is not placed or looped under the client's leg. The tubing must drain freely at all times.

44) D

- A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest, because a direct correlation exists between proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.

45) D

- A potential complication of hemodialysis is the acquisition of dialysis-associated hepatitis B. This is a concern for clients (who may carry the virus), client families (at risk from contact with the client and with environmental surfaces), and staff (who may acquire the virus from contact with the client's blood). This risk is minimized by the use of standard precautions, appropriate handwashing and sterilization procedures, and the prohibition of eating, drinking, or other hand-to-mouth activity in the hemodialysis unit. The first nurse should ask the second nurse to stop eating and drinking in the client area.



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Nursing Leadership NCLEX Questions (36-40)

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36. A registered nurse is a preceptor for a new nursing graduate an is describing critical paths and variance analysis to the new nursing graduate. The registered nurse instructs the new nursing graduate that a variance analysis is performed on all clients:

a) continuously
b) daily during hospitalization
c) every third day of hospitalization
d) every other day of hospitalization

37. When a nurse manager makes a decisions regarding the management of the nursing unit without input from the staff, the type of leadership style that the nurse manager is demonstrating is:

a) autocratic
b) situational
c) democratic
d) laissez-faire

38. A charge nurse knows that drug and alcohol use by nurses is a reason for the increasing numbers of disciplinary cares by the Board of Nursing. The charge nurse understands that when dealing with a nurse with such an illness, it is most important to assess the impaired nurse to determine:

a) the magnitude of drug diversion over time
b) if falsification of clients records occurred
c) the types of illegal activities related to the abuse
d) the physiological impact of the illness on practice

39. A nurse manager is planning to implement a change in the method of the documentation system for the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The initial step in the process of change for the nurse manager is which of the following?

a) plan strategies to implement the change
b) set goals and priorities regarding the change process
c) identify the inefficiency that needs improvement or correction
d) identify potential solutions and strategies for the change process

40. A nurse receives a telephone call from the emergency department and is told that a child with a diagnosis of tonic-clonic seizures will be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs assistant to place which items at the bedside?

a) a tracheostomy set and oxygen
b) suction apparatus and an airway
c) an endotracheal tube and an airway
d) an emergency cart and laryngoscope








Nursing Leadership NCLEX Questions
Answers and Rationale

36) A

- Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options B, C and D are incorrect.

37) A

- The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The situational leadership style utilizes a style depending on the situation and events. The laissez-faire style allows staff to work without assistance, direction, or supervision.

38) D

- A nurse must be able to function at a level that does not affect the ability to provide safe, quality care. The highest priority is to determine how the illness affects the nurse's ability to practice. The other options will be addressed if an investigation is carried out.

39) C

- When beginning the change process, the nurse should identify and define the problem that needs improvement or correction. This important first step can prevent many future problems, because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.

40) B

- Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the major complications during and following a seizure. Suction is helpful to prevent choking and cyanosis. Options A and C are incorrect because inserting an endotracheal tube or a tracheostomy is not done. It is not necessary to have an emergency cart (which contains a laryngoscope) at the bedside, but a cart should be available in the treatment room or on the nursing unit.


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Nursing Leadership NCLEX Questions (41-45)

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Nursing Leadership NCLEX Questions (31-35)

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31. Based upon a request made by the client's spouse and children, a physician asks a nurse to discontinue the feeding tube in a client who is in chronic debilitated and comatose state. The nurse understands the legal basis for carrying out the order and first checks the client's record for documentation of:

a) a court approval to discontinue the treatment
b) approval by the institutional Ethics Committee
c) a written order by the physician to remove the tube
d) authorization by the family to discontinue the treatment

32. A nurse plans to carry out a multidisciplinary research project on the effects of immobility on client's stress levels. Of the following statements, which principle is most important when planning this project?

a)  any client has the right to refuse to participate in research studies
b) collaboration with other disciplines is essential to the successful practice of nursing
c) the cooperation of the physicians on staff must be ensured in order for the project to succeed
d) the corporate nurse executive should be consulted, because the project will take nursing time

33. A nurse manager has identified a problem on the nursing unit and holds unit meetings for all shifts. The nurse manager presents an analysis of the problem and proposals for actions to team members and invites the team members to comment and provide input. Which style of leadership is the nurse manager specifically employing?

a)  situational
b) laissez-faire
c) participative
d) authoritarian

34. A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame, does not problem-solve situations, and does not prioritize nursing care. The charge nurse has the responsibility to:

a)  supervise the staff nurse more closely so that tasks are completed
b) ask other staff members to help the staff nurse get the work done
c) provide support and identify the underlying cause of the staff nurse's problem
d) report the staff nurse to the supervisor so that something is done to resolve the problem


35. A registered nurse is preceptor for a new nursing graduate and is observing the new nursing graduate organize the client assignment and daily tasks. The registered nurse intervenes if the new nursing graduate does which of the following?

a) provide time for unexpected tasks
b) lists the supplies needed for a task
c) prioritizes client needs and daily tasks
d) plans to document task completion at the end of the day





Nursing Leadership NCLEX Questions
Answers and Rationale

31) D

- The family or a legal guardian can make treatment decisions for the client who is unable to do so. Once the decision is made, the physician writes the order. Generally, the family makes decisions in collaboration with physicians, other health care workers, and other trusted advisors. Although a written order by the physician is necessary, the nurse first checks for documentation of the family's request. Unless special circumstances exist, a court order is not necessary. Although some health care agencies may require reviewing such requests via the Ethics Committee, this is not the nurse's first action.

32) A

- The proposed project is research and includes human subjects. Although options B, C, and D need to be considered, they are all secondary to the overriding principle of the legal and ethical practice of nursing that any client has the right to refuse to participate in research using human subjects.

33) C

- Participative leadership demonstrates an "in-between" style, neither authoritarian nor democratic style. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. The autocratic style of leadership is task oriented and directive. The situational leadership style utilizes a style depending on the situation and events.

34) C

Option C empowers the charge nurse to assist the staff nurse while trying to identify and reduce the behaviors that make it difficult for the staff nurse to function. Options A, B, and D are punitive actions, shift the burden to other workers, and do not solve the problem.

35) D

- The nurse should document task completion continuously throughout the day. Options A, B, and C identify accurate components of time management.



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Nursing Leadership NCLEX Questions (1-5)


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Nursing Leadership NCLEX Questions (36-40)

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Nursing Questions about Leadership and Management (26-30)

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26. A nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed practical nurse (LPN) is assigned to the client. The appropriate action for the nurse to take is to:

a) reassign  the LPN to the care of clients not receiving opioids
b) notify the physician that the client needs an increase in opioid dosage
c) review the client's medication administration record immediately and discuss the observations with the nursing supervisor
d) confront the LPN with the information about the client having pain control problems and ask if the LPN is using the opioids personally

27. A medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of oral pyridostigmine bromide (Mestinon) to a client with myasthenia gravis. Which observation by the medication nurse would indicate safe practice by the LPN?

a) asking the client to take sips of water
b) asking the client to lie down on his right side
c) asking the client to look up at the ceiling for  30 seconds
d) instructing the client to void before taking the medication

28. During orientation, a graduate nurse learns that the nursing model of practice implemented in the facility is a primary nursing approach. When the nurse attends report on the medical unit, the nurse will verify with the staff which of the following characteristics of primary nursing?

a)  critical paths are used when providing client care
b) the nurse manager assigns tasks to the staff members
c) a registered nurse (RN) leads nursing staff in providing care to a group of clients
d) a single RN is responsible for planning and providing individualized nursing care to clients

29. A clinical nurse manager conducts an inservice educational session for the staff nurses about case management. The clinical nurse manager determines that a review of the material needs to be done if a staff nurse stated that case management:

a)  manages client care by managing the client care environment
b) maximizes hospital revenues while providing for optimal client care
c) is designed to promote appropriate use of hospital personnel and material resources
d) represents a primary health prevention focus managed by a single case manager

30. A nurse manager is reviewing the critical paths of the clients on the nursing unit. The nurse manager collaborates with each nurse assigned to the clients and performs a variance analysis. Which of the following would indicate the need for further action and analysis?

a)  a client is performing his own colostomy care
b) purulent drainage is noted from a postoperative wound incision
c) a 1-day postoperative client has a temperature of 98.8F
d) a client newly diagnosed with diabetes mellitus is preparing his own insulin for injection





Nursing Questions about Leadership and Management
Answers and Rationale

26) C

- In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client's record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is therefore most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. The client does not need an increase in opioids. To reassign the LPN to clients not receiving opioids ignores the issue. A confrontation is not the most advisable action because it could result in an argumentative situation.

27) A

- Myasthenia gravis can affect the client's ability to swallow. The primary assessment is to determine the client's ability to handle oral medications or any oral substance. Options B and C are not appropriate. Option B could result in aspiration and option C has no useful purpose. There is no specific reason for the client to void before taking this medication.

28) D

- Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal-directed, individualized client care. Option A identifies a component of case management. Option B identifies functional nursing. Option C identifies team nursing.

29) D

- Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal client care. It manages client care by managing the client care environment.

30) C 

- Variances are actual deviations or detours from the critical paths. Variances can be either positive or negative, or avoidable or unavoidable and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so that appropriate action can be taken. Option B is the only option that identifies the need for further action.




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Nursing Questions about Leadership and Management (21-25)

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21. A nursing student prepares a postoperative plan of care for a client scheduled for hypophysectomy. The registered nurse reviews the plan and informs the nursing student that the plan needs to be corrected if which of the following was noted?

a) obtain daily weights
b) administer mouth care
c) monitor intake and output
d) encourage coughing and deep breathing

22. A nurse manager is reviewing with the nursing staff the purposes for applying  wrist and ankle restraints (security devices) to a client. The nurse manager determines that further review is necessary when a nursing staff member states that an indication for the use of a restraint is to:

a) limit movement of a limb
b) keep the client in bed at night
c) prevent the violent client from injuring self and others
d) prevent the client from pulling out intravenous lines and catheters

23. A hospitalized client with a diagnosis of anorexia nervosa and in a state of starvation is in two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be inappropriate to assign to this two-bed room?

a)  a client with pneumonia
b) a client who can perform self-care
c) a client with a fractured leg that is casted
d) a client who is scheduled for a diagnostic test

24. A multidisciplinary health care team is planning care for a client with hyperparathyroidism. The nurse identifies which client outcome to the health care team?

a) describes how to take antacids
b) restricts fluids to 1000 ml per day
c) describes how to take antidiarrheal medications
d) walks down the hall for 15 minutes, three times a day

25. A clinic nurse wants to develop a diabetic teaching program. In order to meet the client's needs, the nurse must first:

a)  assess the client's functional abilities
b) ensure that insurance will pay for participation in the program
c) discuss the focus of the program with the multidisciplinary team
d) include everyone who comes into the clinic in the teaching sessions






Nursing Questions about Leadership and Management
Answers and Rationale

21) D

- Toothbrushing, sneezing, coughing, nose blowing, and bending are activities that should be avoided postoperatively in the client who underwent a hypophysectomy. These activities interfere with the healing of the incision and can disrupt the graft. Options A, B, and C are appropriate postoperative interventions.

22) B

- Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. They are applied to prevent the client from injuring self or others; from pulling out intravenous lines, catheters, or tubes; or from removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment.

23) A

- The client in a state of starvation has a compromised immune system. Having a roommate with pneumonia would place the client at risk for infection. Options B, C, and D are appropriate roommates.

24) D

- Mobility of the client with hyperparathyroidism should be encouraged as much as possible because of the calcium imbalance that occurs in this disorder and the predisposition to the formation of renal calculi. Fluids should not be restricted. Options A and C are not specifically associated with this disorder.

25) A

- Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore the nurse must first assess the clients and their needs in order to effectively plan the program. Options B, C, and D do not address the clients' needs.


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Immune System Practice Test (46-50)

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46. A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of Imbalanced nutrition: less than body requirements. The nurse plans which of the following goals with this client?

a)  consume foods and beverages that are high in glucose
b) plan large menus and cook meals in advance
c) eat low-calorie snacks between meals
d) eat small, frequent meals throughout the day

47. A client with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse include in the plan of care to assist the client in performing activities of daily living?

a) provide supportive care with hygiene needs
b) provide meals and snacks with high-protein, high calorie, and high-nutritional value
c) provide small, frequent meals
d) offer low microbial foods

48. A client who was tested for human immunodeficiency virus (HIV) after a recent exposure had a negative result. During the post-test counseling session, the nurse tells the client which of the following?

a) the test should be repeated in 6 months
b) this ensures that the client is not infected with the HIV virus
c) the client no longer needs to protect himself from sexual partners
d) the client probably has immunity to the acquired immunodeficiency virus

49. A client is diagnosed with late stage human immunodeficiency virus (HIV), and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to:

a) tell the client and family to stop smoking because it will predispose the client to respiratory infections
b) tell the client and family that raw or improperly washed foods can produce microbes
c) encourage the client and family to discuss their feelings about the disease
d) advise the client to avoid becoming pregnant because of the risk of transmission of the infection

50. A client is diagnosed  with human immunodeficiency virus (HIV) infection. The nurse prepares a care plan for the client, knowing that HIV is primarily a condition in which:

a) immunosuppression occurs and is indicated by a T4 lymphocyte count of less than 200/mm3
b) bacterial infection occurs, causing weakness
c) fungal infection occurs, causing a rash and pruritus
d) protozoan infection occurs, causing a fever and nonproductive cough





Immune System Practice Test 
Answers and Rationale

46) D

- The client should eat small, frequent meals throughout the day. The client also should take in nutrient-dense and high-calorie meals and snacks rather than those that are high in glucose only. The client is encouraged to eat favorite foods to keep intake up and plan meals that are easy to prepare. The client can also avoid taking fluids with meals to increase food intake before satiety sets in.

47) A
- Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options B, C, and D are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option B will assist the client in maintaining appropriate weight and proper nutrition. Option C will assist the client in tolerating meals better. Option D will decrease the client's risk of infection.

48) A

- A negative test result indicates that no HIV antibodies were detected in the blood sample. A repeated test in 6 months is recommended because false-negative test results have occurred early in the infection. Options B, C, and D are incorrect.

49) C

- The priority psychosocial nursing intervention for the client and family is to encourage the client and family to discuss their feelings about the disease. Options A, B, and D identify physiological not psychosocial concerns.

50) A

- HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoal infection can occur, these occur as opportunistic infections as a result of the immunosuppression.


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GI NCLEX Questions (71-75)

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71. A client receiving parenteral nutrition (PN) complains of nausea, excessive thirst, and increased frequency of voiding. The nurse initially assesses which of the following client data?

a) rectal temperature
b) last serum potasium
c) capillary blood glucose
d) serum blood urea nitrogen and creatinine

72. The nurse provides dietary measures to a client with diverticulosis. The nurse encourages the client to eat foods that are:

a)  high in fat
b) low in fiber
c) high in fiber
d) low roughage

73. A client who undergoes a gastric resection is at risk for developing dumping syndrome. The nurse monitors the client for:

a)  dizziness
b) bradycardia
c) constipation
d) extreme thirst

74. The nurse is caring for a client who is scheduled to have a liver biopsy. Before the procedure, it is most important for the nurse to assess the client's:

a)  tolerance to pain
b) allergy to iodine or shellfish
c) history of nausea and vomiting
d) ability to lie still and hold the breath

75.  A client who has had an abdominal aortic aneurysm repair is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. The nurse should:

a) feed the client
b) call the physician immediately
c) remove the nasogastric (NG) tube
d) document the finding and continue to assess  for bowel sounds







GI NCLEX Questions 
Answers and Rationale

71) C

- The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to assess the client's blood glucose level to verify these data. Clients receiving PN are at risk for hyperglycemia related to the increased glucose load of the solution. The other options would not provide any information that would correlate with the client's symptoms.

72) C

- Diverticulosis is managed by consumption of a high-fiber diet and prevention of constipation with bran and bulk laxatives. A diet high in fat should be avoided because high-fat foods tend to be low in fiber. A low-roughage diet is similar to a low-fiber diet.

73) A

- Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vasomotor disturbances such as dizziness, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

74) D

- It is most important for the nurse to assess the client's ability to lie still and hold the breath for the procedure. This helps the physician avoid complications, such as puncturing the lung or other organs. Assessment of allergy to iodine or shellfish is unnecessary for this procedure, because no contrast dye is used. Knowledge of the history related to nausea and vomiting is generally a part of assessment of the gastrointestinal system but has no relationship to the procedure. The client's tolerance for pain is a useful item to know. However, the area will receive a local anesthetic.

75) D

- Bowel sounds may be absent for 3 to 4 days postoperative due to bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. There is no need to call the physician immediately at this time.


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GI NCLEX Questions (66-70)

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66. A nurse is caring for a client with acute pancreatitis who has a history of alcoholism. The nurse closely monitors the client for paralytic ileus, knowing that which assessment data indicate this complication of pancreatitis?

a) inability to pass flatus
b) loss of anal sphincter control
c) severe, constant pain with rapid onset
d) firm, nontender mass palpable at the lower right costal margin

67. After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. Which of the following descriptions best describes this assessment finding?

a) waves of loud gurgles auscultated in all four quadrants
b) soft gurgling or clicking sounds auscultated in all four quadrants
c) low-pitched swishing sounds auscultated in one or two quadrants
d) very high-pitched loud rushes auscultated especially in one or two quadrants

68. The nurse is assessing a client with a Cantor tube. Which finding indicates correct placement of the tube?

a) a pH of aspirate less than 7.0
b) a pH of aspirate of 7.0 or greater
c) the auscultation of air when inserted into the abdomen
d) the presence of gastric contents when checking residuals

69. Then nurse is assisting the client with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which of the following entree items that could aggravate the client's condition?

a) tomato soup
b) fresh fruit plate
c) vegetable lasagna
d) ground beef patty

70. A client with a colostomy is complaining of gas building up in the colostomy bag. The nurse instructs the client that which of the following food items can be consumed to best prevent this problem?

a) yogurt
b) broccoli
c) cabbage
d) cauliflower






GI NCLEX Questions
Answers and Rationale

66) A

- An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option 4 is the description of the physical finding of liver enlargement. The liver is usually enlarged in the client with cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic ileus.

67) B

- Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively soft gurgling or clicking sounds that occur irregularly 5 to 35 times per minute. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be higher pitched and loud (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. No aortic bruits should be heard.

68) B

- The Cantor tube is an intestinal tube and is used for aspirating intestinal contents. For intestinal intubation the tube is threaded through the nose into the stomach and then through the pylorus, where peristaltic activity of the bowel carries it to the desired intestinal area. The nurse ensures intestinal placement by checking the pH of aspirate. A pH reading greater than 7 indicates intestinal contents; a reading less than 7 indicates gastric contents.

69) D

- Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, buttermilk, onions, peanut butter, and gelatin.

70) A

- Consumption of yogurt, crackers and toast can help to prevent gas. Gas-forming foods include broccoli, mushrooms, cauliflower, onions, peas, and cabbage. These should be avoided by the client with a colostomy until tolerance to them is determined.



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GI NCLEX Questions (61-65)

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61. A client has had a Miller-Abbot tube in place for 24 hours. Which assessment finding indicates that the tube is located in the intestine?

a) the client is nauseous
b) bowel sounds are absent
c) aspirate from the tube has pH of 7
d) the abdominal radiograph report indicates that the end of the tube is above the pylorus

62. A client is resuming a diet after a Billroth II procedure. To minimize complications from eating, the nurse teaches the client to avoid doing which of the following?

a) lying down after eating
b) eating a diet high in protein
c) drinking liquids with meals
d) eating six small meals per day

63. A physician orders the deflation of the esophageal balloon of a Sengstaken-Blakemore tube in a client. The nurse prepares for the procedure, knowing that the deflation of the esophageal balloon places the client at risk for:

a) gastritis
b) increased ascites
c) esophageal necrosis
d) recurrent hemorrhage from the esophageal varices

64. The nurse is preparing to initiate bolus enteral feedings via nasogastric (NG) tube to a client. Which of the following actions represents safe practice by the nurse?

a) checks the volume of the residual after administering the bolus feeding
b) aspirates gastric contents prior to initiating the feeding and assures that pH is >9
c) elevates the head of the bed to 25 degrees and maintains for 30 minutes after instillation of feeding
d) measures the length of the tube from where it protrudes from the nose to the end and compares to previously documented measurements

65. A nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing, and as the nurse starts to slowly advance the NGT with each swallow, the client begins ti gag. Which nursing action would least likely result in proper tube insertion and promote client relaxation?

a) pulling the tube back slightly
b) instructing the client to breathe slowly
c) continuing to advance the tube to the desired distance
d) checking the back of the pharynx using a tongue blade and flashlight







GI NCLEX Questions
Answers and Rationale

61) C

- The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and to correct a bowel obstruction. The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is alkaline (7 or higher). Location of the tube can also be determined by radiographs.

62) C

- The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.

63) D

- A Sengstaken-Blakemore tube is inserted in clients with cirrhosis who have ruptured esophageal varices. It has esophageal and gastric balloons. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to the esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices.

64) D

- After initial radiographic confirmation of NG tube placement, methods used to verify nasogastric tube placement include measuring the length of the tube from the point it protrudes from the nose to the end; injecting 10 to 30 mL of air into the tube and auscultating over the left upper quadrant of the abdomen; and aspirating the secretions and checking to see if the pH is between 1 and 5. Fowler's position is recommended for bolus feedings, if permitted, and should be maintained for 1 hour after instillation. Residual should be assessed before administration of the next feeding.

65) C

- As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause gagging. Instead of passing through to the esophagus, the NG tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx, advancing the tube may position it in the trachea. Slow breathing helps the client relax to reduce the gag response. The tube may be advanced after the client relaxes.


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Nursing Fundamentals Course (71-75)

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71. The nurse inserts an indwelling urinary catheter into a male client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which should the nurse implement next?

a) inflate the balloon with water
b) insert the catheter 2.5 to 5 cm
c) measure the initial urine output
d) secure the catheter to the client

72. A nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen?

a) ask the client to obtain the specimen after breakfast
b) use a sterile plastic container for obtaining the specimen
c) provide tissues for expectoration and obtaining the specimen
d) ask the client to expectorate a small amount of sputum into the emesis basin

73. A client who is 40 years old has a severe mental impairment and is scheduled fro gallbladder surgery. Which should the nurse implement about the informed consent first to facilitate the scheduled surgery?

a) check for the identity of the client's legal guardian
b) inform the legal guardian about advanced directives
c) arrange fro the surgeon to provide informed consent
d) ensure that the legal guardian signed the informed consent

74. Which action does the nurse implement to obtain a urine specimen for a urinalysis from a female client with an indwelling urinary catheter?

a) detach the tubing of the drainage bag
b) use a sterile container for the specimen
c) cleanse the perineum from front to back
d) aspirate the urine from the drainage bag port

75. The nurse has given a subcutaneous injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse disposes of the used needle and syringe by:

a) breaking the needle before discarding it
b) recapping the needle and discarding the syringe in a disposal unit
c) placing the uncapped needle and syringe in a labeled cardboard box
d) placing the uncapped needle and syringe in labeled, rigid plastic container







Nursing Fundamentals Course
Answers and Rationale

71) B

- The catheter's balloon is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5 cm further after urine begins to flow in order to provide sufficient space to inflate the balloon. After the nurse secures the catheter to the client's leg, the nurse measures the initial urine output.

72) B

- Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques, because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. A first morning specimen is preferred because it represents overnight secretions of the tracheobronchial tree.

73) A

- The client is not competent to sign an informed consent, so the nurse verifies the identity of the client's legal guardian to fulfill part of the nurse's duty in informed consent. This helps avoid improperly signed documents and to direct the surgeon to the legal representatives of the client's interests. Most states require client notification of advanced directives at admission.

74) D

- A specimen for urinalysis does not need to be sterile; however, the system must remain sterile to reduce the risk of infection. Therefore, the nurse obtains the specimen using sterile technique and obtains a fresh specimen by aspirating urine from the drainage bag port after sanitizing the port and inserting a sterile needle. The nurse avoids breaking the integrity of the urinary collection system to prevent contamination. The nurse also avoids taking urine from the urinary drainage bag because the urine is less likely to reflect the current client status and because urine undergoes chemical changes and particulate matter settles over time. A sterile container is unnecessary for a urinalysis, and because the client has an indwelling catheter, perineal cleansing before obtaining a urine specimen is unnecessary.

75) D

- Standard precautions include specific guidelines for handling of needles. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container specific for this purpose. Needles should not be discarded in cardboard boxes, because these types of boxes are not impervious. Needles should never be left lying around after use.


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NCLEX Review - Fundamentals of Nursing 7th edition (66-70)

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66. A nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. Which nursing action is appropriate in this situation?

a) obtain a dust pan and mop to sweep up the syringe
b) call the housekeeping department to pick up the syringe
c) carefully pick up the syringe from the floor and gently recap the needle
d) carefully pick up the syringe from the floor and dispose of it in a sharps container

67. A nurse is observing a client using a walker. The nurse determines that the client is using the walker correctly if the client:

a) puts weight on the hand pieces, moves the walker forward, and then walks into it
b) puts weight on the hand pieces, slides the walker forward, and then walks into it
c) puts all four points of the walker flat on the floor, puts weight on the hand pieces, and then walks into it
d) walks into the walker, puts weight on the hand pieces, and then puts all four points the walker flat on the floor

68. The nurse observes clients to evaluate for the correct height of crutches. Which client is correctly fitted with crutches?

a) the client stands with the axillae on the top of the crutches
b) a pencil can slide between the client's axillae and the top of the crutches
c) the client keeps the arms straight when standing with crutches
d) two fingers fit between the client's axillae ad the top of the crutches


69. A client is at risk for infection following a radical vulvectomy. Which does the nurse implement when giving perineal care to this client?


a) provides a sitz bath
b) provides care twice a day
c) applies a fresh sterile dressing
d) cleanses using warm tap water

70. A nurse prepares to assist postoperative client to progress from a lying to sitting position to prepare for ambulation. Which nursing action is appropriate to maintain the safety on the client?

a) assess the client for signs of dizziness and hypotension
b) allow the client to rise from the bed to a standing position unassisted
c) elevate the head of the bed quickly to assist the client to a sitting position
d) assist the client to move quickly from the lying position to to the sitting position








Fundamentals of Nursing 7th edition
Answers and Rationale

66) D

- Syringes should never be recapped, in any circumstances, because of the risk of getting pricked with a contaminated needle. Used syringes should always be placed in a sharps container immediately after use to avoid individuals from becoming injured. A syringe should not be swept up, because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringe.

67) C

When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four points of the walker 2 feet forward flat on the floor before putting weight on the hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it.

68) D

With the client's elbows flexed 20 to 30 degrees, the shoulders in a relaxed position, and the crutches placed approximately 15 cm (6 inches) anterolateral from the toes, the nurse should be able to place two fingers comfortably between the client's axillae and the axillary bars. The crutches are adjusted if there is too much or too little space at the axillary area. The client is advised to avoid resting the axillae on the axillary bars because this could injure the brachial plexus (the nerves in the axillae that supply the arm and shoulder area). The nurse should terminate ambulation and recheck the crutch height if the client complains of numbness or tingling in the hands or arms.

69) A

The nurse provides a sitz bath to soothe tissues and to stimulate healing by increasing the regional blood flow. Perineal care is provided at least twice a day and after each voiding and bowel movement. A dressing is not used for a vulvectomy. Sterile solutions are used for perineal care using a sterile syringe or water pick.

70) A

- Early ambulation should not exceed the client's tolerance. The client should be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client's side to provide physical support and encouragement.


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Fundamentals Nursing Test Bank (61-65)

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61. After receiving detailed information about a colonoscopy from the provider, the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement?

a) contact the provider to obtain informed consent
b) obtain a verbal informed consent from the client
c) have two nurses witness the client sign with an X
d) clarify information to the client with another nurse

62. The nurse documents an entry regarding client care in the client's medical record. When checking the entry, the nurse notices some incorrect information. Which should the nurse implement?

a) obliterate the incorrect information with a black marker
b) use correction fluid to cover up the incorrect information
c) erase the error completely and write in the correct information
d) draw a line through the incorrect information and initial the change

63. The nurse prepares to suction a client through a tracheostomy tube. Which should the nurse wear to perform this procedure?

a) mask, gown, and a cap
b) mask, sterile gloves, and a cap
c) gown, mask, and sterile gloves
d) goggles, mask, and sterile gloves

64. The nurse instructs a client how to use crutches safely for ambulating at home. Which instruction should the nurse recommend to minimize the risk of falls?

a) remove all area rugs
b) wear soft, slip-on shoes
c) use the bathtub's grab bars
d) remove pets from the home

65. The nurse observes than an older postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to help avoid episodes of agitation?

a) gently hold the client's hand while speaking
b) wait until the client's agitation has subsided
c) speak while moving slowly toward the client
d) speak to the client from the entrance to the room





Fundamentals Nursing Test Bank
Answers and Rationale

61) C

- Nurses are responsible to make sure the signed informed consent form is in the client's medical record prior to a procedure and for clarifying facts presented by the provider. Nonetheless, the person performing the procedure obtains informed consent and provides the explanations to the client. Informed consent can be obtained verbally, but that is also the responsibility of the provider. Clients who cannot write may sign an informed consent with an X in the presence of two witnesses. Nurses can serve as a witness to the client's signature but not to the fact that the client is informed.

62) D

- To correct an error documented in a medical record, the nurse draws one line through the incorrect information and then initials the error. The information remains visible and properly labeled as incorrect. Errors are never erased, and correction fluid or black markers are never used on a legal document such as the medical record.

63) D

- The nurse should wear a mask and goggles when suctioning the client. Sterile gloves are also worn unless suctioning is performed using a closed suctioning system. A mask offers full protection of the nurse's nose and mouth, and goggles protect the nurse's eyes from getting splashed with sputum. A gown protects the nurse's uniform, and a cap protects the nurse's hair, but these items are not required for suctioning a client.

64) A

- To reduce the risk of falls, the nurse recommends the removal of all obstacles and trip hazards from the home. Tie-on shoes with nonslip soles should be worn while crutch walking. Grab bars in the bath tub or shower will not necessarily assist the client while walking with crutches. Not all pets are trip hazards (e.g., fish, birds, guinea pigs).

65) C

- Speaking and moving slowly toward the client will prevent the client from becoming further agitated, because any sudden moves or speaking too quickly may cause the client to have a violent episode. Holding the client's hand can be misinterpreted by a client to mean restraint. If the client's agitation is not addressed, it is likely to increase; therefore, waiting for the agitation to subside is not a suitable option. Remaining at the entrance of the room can make the client feel alienated.


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Fundamentals of Nursing Quiz (56-60)

Welcome to Fundamentals of Nursing Quiz. 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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Enjoy answering and I hope that NCLEX Review and Secrets can somehow help you in your future examination. Good Luck



56. A client receives cardiopulmonary resuscitation in the emergency department, but it is unsuccessful. The wife of the client indicates that the client is an organ donor and that they want to donate the client's eyes. Which should the nurse implement first to promote organ transplantation?

a) confirm that the client is a valid donor with an organ registry
b) cover the eyes with wet saline gauze pads and small ice packs
c) place the client in a supine position with the head on one pillow
d) ask the wife to produce the legal documents supporting the donation

57. The nurse prepares a client for discharge who needs intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line. Which should the nurse include in client teaching about daily infusion care in the home?

a) keep the affected arm immobilized
b) aspirate 3 ml of blood from the PICC line
c) maintain a continuous intravenous infusion
d) check the insertion site for redness and swelling

58. The nurse is in orientation for a full-time position as a case manager. Which should the nurse implement related to professional liability insurance?

a) obtain his own malpractice insurance
b) wait for six months to a year to decide
c) rely on the agency for liability insurance
d) discontinue his own malpractice insurance

59. In the role of a caregiver, the nurse's primary responsibility is to assess the client's ability to:

a) protect self
b) set own goals
c) decide the best approach(es) for care
d) restore physical, emotional, and social well-being

60. The nurse prepares a client who has a right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright, into which alternate position does the nurse assist the client to maintain safety during the procedure?

a) right side-lying with the head of the bed flat
b) prone with the head turned toward the affected side
c) sim's position with the head of the bed elevated 45 degrees
d) left side-lying with the head of the bed elevated 45 degrees








Fundamentals of Nursing Quiz
Answers and Rationale

56) B

- When a corneal donor dies, the eyes are closed, covered with sterile gauze pads wet with saline, and cooled with small ice packs. Within 2 to 4 hours the eyes are harvested, and the cornea is usually transplanted within 24 to 48 hours after harvesting. The head of the bed is elevated 30 to 45 degrees to prevent edema and tissue damage. Calling an organ registry and asking the wife to produce documents does not promote organ transplantation.

57) D

- A PICC is designed for long-term intravenous infusions and, usually, is inserted into the median cubital vein with the terminal end of the catheter in the superior vena cava. Although the risk of infection is less with a PICC line than with a central venous catheter, it is possible for phlebitis or infection to develop. Clients must inspect the insertion site and affected arm daily and report any discharge, redness, swelling, or pain to the nurse or provider immediately. A PICC line does not require the affected arm to be immobilized and can be used for intermittent or continuous fluid infusion. Although a PICC line can be used to obtain a blood specimen, the risk of occlusion from aspirating blood as part of the related daily care is greater than any potential benefit.

58) A

- Nurses need individual liability insurance policies for protection against malpractice lawsuits beginning on the first day of employment. Many agencies discourage nurses from obtaining professional malpractice insurance because, if a plaintiff brings a suit against the nurse or the hospital, the agency prefers to have their attorneys in control. However, this may not be in the best interests of an individual nurse, and, if the nurse breached any agency policy, the hospital can deny legal protection to the nurse. Still, nurses should be aware that carrying malpractice insurance increases the likelihood of being named in a suit at the onset of the case, especially when the plaintiff is seeking monetary compensation.

59) D

- A primary role of the caregiver is to assess the client's ability to restore well-being. Options A, B, and C identify the nurse's role as a client advocate.

60) D

- Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.


After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

Fundamentals of Nursing Quiz (1-5)


Or proceed to the next set of questions:

Fundamentals of Nursing Quiz (61-65)

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