NCLEX Practice Exam 26 (50 Questions)

NCLEX Practice Exam 26 (50 Questions)

This 50-item exam contains various questions about Medical-Surgical Nursing that covers topics of Colostomy Care, Diagnostic Tests, and several diseases.

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Topics

Topics or concepts included in this exam are:

  • Various questions about Medical-Surgical Nursing
  • Colostomy Care
  • Diagnostic Tests
  • Various Diseases

Guidelines

Follow the guidelines below to make the most out of this exam:

  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales (if any) are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.

Questions

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NCLEX Practice Exam 26 (50 Questions)

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NCLEX Practice Exam 26 (50 Questions)

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1. Stacy’s mother states to the nurse that it is hard to see Stacy with no hair. The best response for the nurse is:

A. “Stacy looks very nice wearing a hat”.
B. “You should not worry about her hair, just be glad that she is alive”.
C. “Yes, it is upsetting. But try to cover up your feelings when you are with her or else she may be upset”.
D. “This is only temporary; Stacy will re-grow new hair in 3-6 months but may be different in texture”.

2. Stacy has beginning stomatitis. To promote oral hygiene and comfort, the nurse-in-charge should:

A. Provide frequent mouthwash with normal saline.
B. Apply viscous Lidocaine to oral ulcers as needed.
C. Use lemon glycerine swabs every 2 hours.
D. Rinse mouth with Hydrogen Peroxide.

3. During the administration of chemotherapy agents, Nurse Oliver observed that the IV site is red and swollen when the IV is touched Stacy shouts in pain. The first nursing action to take is:

A. Notify the physician
B. Flush the IV line with saline solution
C. Immediately discontinue the infusion
D. Apply an ice pack to the site, followed by warm compress.

4. The term “blue bloater” refers to a male client which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

5. The term “pink puffer” refers to the female client with which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)
B. Asthma
C. Chronic obstructive bronchitis
D. Emphysema

6. Jose is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the paco2 to be which of the following values?

A. 15 mm Hg
B. 30 mm Hg
C. 40 mm Hg
D. 80 mm Hg

7. Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm Hg; Pao2 46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents which of the following conditions?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

8. Norma has started a new drug for hypertension. Thirty minutes after she takes the drug, she develops chest tightness and becomes short of breath and tachypneic. She has a decreased level of consciousness. These signs indicate which of the following conditions?

A. Asthma attack
B. Pulmonary embolism
C. Respiratory failure
D. Rheumatoid arthritis

Situation: Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver:

9. Which laboratory test indicates liver cirrhosis?

A. Decreased red blood cell count
B. Decreased serum acid phosphatase level
C. Elevated white blood cell count
D. Elevated serum aminotransferase

10. The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at increased risk for excessive bleeding primarily because of:

A. Impaired clotting mechanism
B. Varix formation
C. Inadequate nutrition
D. Trauma of invasive procedure

11. Mr. Gonzales develops hepatic encephalopathy. Which clinical manifestation is most common with this condition?

A. Increased urine output
B. Altered level of consciousness
C. Decreased tendon reflex
D. Hypotension

12. When Mr. Gonzales regained consciousness, the physician orders 50 ml of Lactulose p.o. every 2 hours. Mr. Gonzales develops diarrhea. The nurse best action would be:

A. “I’ll see if your physician is in the hospital”.
B. “Maybe you’re reacting to the drug; I will withhold the next dose”.
C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.
D. “Frequently, bowel movements are needed to reduce sodium level”.

13. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm?

A. Lower back pain, increased blood pressure, decreased red blood cell (RBC) count, increased white blood (WBC) count.
B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.
C. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count.
D. Intermittent lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.

14. After undergoing a cardiac catheterization, Tracy has a large puddle of blood under his buttocks. Which of the following steps should the nurse take first?

A. Call for help.
B. Obtain vital signs
C. Ask the client to “lift up”
D. Apply gloves and assess the groin site

15. Which of the following treatment is a suitable surgical intervention for a client with unstable angina?

A. Cardiac catheterization
B. Echocardiogram
C. Nitroglycerin
D. Percutaneous transluminal coronary angioplasty (PTCA)

16. The nurse is aware that the following terms used to describe reduced cardiac output and perfusion impairment due to ineffective pumping of the heart is:

A. Anaphylactic shock
B. Cardiogenic shock
C. Distributive shock
D. Myocardial infarction (MI)

17. A client with hypertension ask the nurse which factors can cause blood pressure to drop to normal levels?

A. Kidneys’ excretion to sodium only.
B. Kidneys’ retention of sodium and water
C. Kidneys’ excretion of sodium and water
D. Kidneys’ retention of sodium and excretion of water

18. Nurse Rose is aware that the statement that best explains why furosemide (Lasix) is administered to treat hypertension is:

A. It dilates peripheral blood vessels.
B. It decreases sympathetic cardioacceleration.
C. It inhibits the angiotensin-converting enzymes
D. It inhibits reabsorption of sodium and water in the loop of Henle.

19. Nurse Nikki knows that laboratory results supports the diagnosis of systemic lupus erythematosus (SLE) is:

A. Elevated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia, elevated antinuclear antibody (ANA) titer
D. Leukocytosis, elevated blood urea nitrogen (BUN) and creatinine levels

20. Arnold, a 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse the headache is severe and she would like her son to have something stronger. Which of the following responses by the nurse is appropriate?

A. “Your son had a mild concussion, acetaminophen is strong enough.”
B. “Aspirin is avoided because of the danger of Reye’s syndrome in children or young adults.”
C. “Narcotics are avoided after a head injury because they may hide a worsening condition.”
D. Stronger medications may lead to vomiting, which increases the intracranial pressure (ICP).”

21. When evaluating an arterial blood gas from a male client with a subdural hematoma, the nurse notes the Paco2 is 30 mm Hg. Which of the following responses best describes the result?

A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)
B. Emergent; the client is poorly oxygenated
C. Normal
D. Significant; the client has alveolar hypoventilation

22. When prioritizing care, which of the following clients should the nurse Olivia assess first?

A. A 17-year-old client 24-hours post appendectomy
B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome
C. A 50-year-old client 3 days post myocardial infarction
D. A 50-year-old client with diverticulitis

23. JP has been diagnosed with gout and wants to know why colchicine is used in the treatment of gout. Which of the following actions of colchicines explains why it’s effective for gout?

A. Replaces estrogen
B. Decreases infection
C. Decreases inflammation
D. Decreases bone demineralization

24. Norma asks for information about osteoarthritis. Which of the following statements about osteoarthritis is correct?

A. Osteoarthritis is rarely debilitating
B. Osteoarthritis is a rare form of arthritis
C. Osteoarthritis is the most common form of arthritis
D. Osteoarthritis affects people over 60

25. Ruby is receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. The nurse understands that skipping this medication will put the client at risk for developing which of the following life threatening complications?

A. Exophthalmos
B. Thyroid storm
C. Myxedema coma
D. Tibial myxedema

26. Nurse Sugar is assessing a client with Cushing’s syndrome. Which observation should the nurse report to the physician immediately?

A. Pitting edema of the legs
B. An irregular apical pulse
C. Dry mucous membranes
D. Frequent urination

27. Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client’s urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal serum osmolality level
D. Below-normal urine osmolality level, above-normal serum osmolality level

28. Jomari is diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which of the following statements indicates that the client understands her condition and how to control it?

A. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”
B. “If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar.”
C. “I will have to monitor my blood glucose level closely and notify the physician if it’s constantly elevated.”
D. “If I begin to feel especially hungry and thirsty, I’ll eat a snack high in carbohydrates.”

29. A 66-year-old client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse would suspect which of the following disorders?

A. Diabetes mellitus
B. Diabetes insipidus
C. Hypoparathyroidism
D. Hyperparathyroidism

30. Nurse Lourdes is teaching a client recovering from Addisonian crisis about the need to take fludrocortisone acetate and hydrocortisone at home. Which statement by the client indicates an understanding of the instructions?

A. “I’ll take my hydrocortisone in the late afternoon, before dinner.”
B. “I’ll take all of my hydrocortisone in the morning, right after I wake up.”
C. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”
D. “I’ll take the entire dose at bedtime.”

31. Which of the following laboratory test results would suggest to the nurse Len that a client has a corticotropin-secreting pituitary adenoma?

A. High corticotropin and low cortisol levels
B. Low corticotropin and high cortisol levels
C. High corticotropin and high cortisol levels
D. Low corticotropin and low cortisol levels

32. A male client is scheduled for a transsphenoidal hypophysectomy to remove a pituitary tumor. Preoperatively, the nurse should assess for potential complications by doing which of the following?

A. Testing for ketones in the urine
B. Testing urine specific gravity
C. Checking temperature every 4 hours
D. Performing capillary glucose testing every 4 hours

33. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Mariner should expect the dose’s:

A. onset to be at 2 p.m. and its peak to be at 3 p.m.
B. onset to be at 2:15 p.m. and its peak to be at 3 p.m.
C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.
D. onset to be at 4 p.m. and its peak to be at 6 p.m.

34. The physician orders laboratory tests to confirm hyperthyroidism in a female client with classic signs and symptoms of this disorder. Which test result would confirm the diagnosis?

A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test
B. A decreased TSH level
C. An increase in the TSH level after 30 minutes during the TSH stimulation test
D. Below-normal levels of serum triiodothyronine (T3) and serum thyroxine (T4) as detected by radioimmunoassay

35. Rico with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U-100 regular insulin and 35 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
B. “Rotate injection sites within the same anatomic region, not among different regions.”
C. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”

36. Nurse Sarah expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?

A. Elevated serum acetone level
B. Serum ketone bodies
C. Serum alkalosis
D. Below-normal serum potassium level

37. For a client with Graves’ disease, which nursing intervention promotes comfort?

A. Restricting intake of oral fluids
B. Placing extra blankets on the client’s bed
C. Limiting intake of high-carbohydrate foods
D. Maintaining room temperature in the low-normal range

38. Patrick is treated in the emergency department for a Colles’ fracture sustained during a fall. What is a Colles’ fracture?

A. Fracture of the distal radius
B. Fracture of the olecranon
C. Fracture of the humerus
D. Fracture of the carpal scaphoid

39. Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

A. Calcium and sodium
B. Calcium and phosphorous
C. Phosphorous and potassium
D. Potassium and sodium

40. Johnny a firefighter was involved in extinguishing a house fire and is being treated to smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. He most likely has developed which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)
B. Atelectasis
C. Bronchitis
D. Pneumonia

41. A 67-year-old client develops acute shortness of breath and progressive hypoxia requiring right femur. The hypoxia was probably caused by which of the following conditions?

A. Asthma attack
B. Atelectasis
C. Bronchitis
D. Fat embolism

42. A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this?

A. Acute asthma
B. Chronic bronchitis
C. Pneumonia
D. Spontaneous pneumothorax

43. A 62-year-old male client was in a motor vehicle accident as an unrestrained driver. He’s now in the emergency department complaining of difficulty of breathing and chest pain. On auscultation of his lung field, no breath sounds are present in the upper lobe. This client may have which of the following conditions?

A. Bronchitis
B. Pneumonia
C. Pneumothorax
D. Tuberculosis (TB)

44. If a client requires a pneumonectomy, what fills the area of the thoracic cavity?

A. The space remains filled with air only
B. The surgeon fills the space with a gel
C. Serous fluids fills the space and consolidates the region
D. The tissue from the other lung grows over to the other side

45. Hemoptysis may be present in the client with a pulmonary embolism because of which of the following reasons?

A. Alveolar damage in the infarcted area
B. Involvement of major blood vessels in the occluded area
C. Loss of lung parenchyma
D. Loss of lung tissue

46. Alvin with a massive pulmonary embolism will have an arterial blood gas analysis performed to determine the extent of hypoxia. The acid-base disorder that may be present is?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

47. After a motor vehicle accident, Armand a 22-year-old client is admitted with a pneumothorax. The surgeon inserts a chest tube and attaches it to a chest drainage system. Bubbling soon appears in the water seal chamber. Which of the following is the most likely cause of the bubbling?

A. Air leak
B. Adequate suction
C. Inadequate suction
D. Kinked chest tube

48. Nurse Michelle calculates the IV flow rate for a postoperative client. The client receives 3,000 ml of Ringer’s lactate solution IV to run over 24 hours. The IV infusion set has a drop factor of 10 drops per milliliter. The nurse should regulate the client’s IV to deliver how many drops per minute?

A. 18
B. 21
C. 35
D. 40

49. Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?

A. 1.2 ml
B. 2.4 ml
C. 3.5 ml
D. 4.2 ml

50. Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful?

A. “I will wear the stockings until the physician tells me to remove them.”
B. “I should wear the stockings even when I am asleep.”
C. “Every four hours I should remove the stockings for a half hour.”
D. “I should put on the stockings before getting out of bed in the morning.”

Answers and Rationale

Gauge your performance by counter checking your answers to the answers below. Learn more about the question by reading the rationale. If you have any disputes or questions, please direct them to the comments section.

1. Answer: D. “This is only temporary; Stacy will re-grow new hair in 3-6 months but may be different in texture”.

  • Option D: This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.

2. Answer: B. Apply viscous Lidocaine to oral ulcers as needed.

  • Option B: Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care.
  • Options A, C, and D: When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.

3. Answer: C. Immediately discontinue the infusion

  • Option C: Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.

4. Answer: C. Chronic obstructive bronchitis

  • Option C: Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis.
  • Option A: Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen.
  • Option B: Clients with asthma don’t exhibit characteristics of chronic disease.
  • Option D: Clients with emphysema appear pink and cachectic.

5. Answer: D. Emphysema

  • Option D: Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.”
  • Option A: Clients with ARDS are usually acutely short of breath.
  • Option B: Clients with asthma don’t have any particular characteristics.
  • Option C: Clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

6. Answer: D. 80 mm Hg

  • Option D: A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.

7. Answer: C. Respiratory acidosis

  • Option C: Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis.
  • Options B and D: The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities.
  • Option A: If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.

8. Answer: C. Respiratory failure

  • Option C: The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure.
  • Options A and B: Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first.
  • Option D: Rheumatoid arthritis doesn’t manifest these signs.

9. Answer: D. Elevated serum aminotransferase

  • Option D: Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.

10. Answer: A. Impaired clotting mechanism

  • Option A: Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.

11. Answer: B. Altered level of consciousness

  • Option B: Changes in behavior and level of consciousness are the first signs of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.

12. Answer: C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4 stools a day”.

  • Option C: Lactulose is given to a patient with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates overdosage and the nurse must reduce the amount of medication given to the patient. The stool will be mushy or soft. Lactulose is also very sweet and may cause cramping and bloating.

13. Answer: B. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count.

  • Option B: Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury.

14. Answer: D. Apply gloves and assess the groin site

  • Option D: Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determines how much blood has been lost. The goal in this situation is to stop the bleeding.
  • Option A: The nurse would call for help if it were warranted after the assessment of the situation.
  • Option B: After determining the extent of the bleeding, vital signs assessment is important.
  • Option C: The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.

15. Answer: D. Percutaneous transluminal coronary angioplasty (PTCA)

  • Option D: PTCA can alleviate the blockage and restore blood flow and oxygenation.
  • Option B: An echocardiogram is a noninvasive diagnosis test.
  • Option C: Nitroglycerin is an oral sublingual medication.
  • Option A: Cardiac catheterization is a diagnostic tool – not a treatment.

16. Answer: B. Cardiogenic shock

  • Option B: Cardiogenic shock is shock related to ineffective pumping of the heart.
  • Option A: Anaphylactic shock results from an allergic reaction.
  • Option C: Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output.
  • Option D: MI isn’t a shock state, though a severe MI can lead to shock.

17. Answer: C. Kidneys’ excretion of sodium and water

  • Option C: The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic blood pressure by regulating blood volume.
  • Option B: Sodium or water retention would only further increase blood pressure.
  • Option D: Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.

18. Answer: D. It inhibits reabsorption of sodium and water in the loop of Henle.

  • Option D: Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure.
  • Option A: Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure.
  • Option B: Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure.
  • Option C: Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.

19. Answer: C. Pancytopenia, elevated antinuclear antibody (ANA) titer

  • Option C: Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels.
  • Option D: Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.

20. Answer: C. Narcotics are avoided after a head injury because they may hide a worsening condition.

  • Option C: Narcotics may mask changes in the level of consciousness that indicate increased ICP.
  • Option A: Acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate.
  • Option B: Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome.
  • Option D: Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.

21. Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP)

  • Option A: A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels.
  • Option B: Oxygenation is evaluated through Pao2 and oxygen saturation.
  • Option D: Alveolar hypoventilation would be reflected in an increased Paco2.

22. Answer: B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome

  • Option B: Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There’s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

23. Answer: C. Decreases inflammation

  • Option C: The action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid.
  • Options A, B, and D: Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.

24. Answer: C. Osteoarthritis is the most common form of arthritis

  • Option C: Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.

25. Answer: C. Myxedema coma

  • Option C: Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn’t taken.
  • Option A: Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism.
  • Option B: Thyroid storm is life-threatening but is caused by severe hyperthyroidism.
  • Option D: Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn’t life-threatening.

26. Answer: B. An irregular apical pulse

  • Option B: Because Cushing’s syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician.
  • Option A: Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention.
  • Options C and D: Dry mucous membranes and frequent urination signal dehydration, which isn’t associated with Cushing’s syndrome.

27. Answer: D. Below-normal urine osmolality level, above-normal serum osmolality level

  • Option D: In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level.
  • Options A, B, and C: For the same reasons, diabetes insipidus doesn’t cause above-normal urine osmolality or below-normal serum osmolality levels.

28. Answer: A. “I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual.”

  • Option A: Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS.
  • Option B: Drinking a glass of non-diet soda would be appropriate for hypoglycemia.
  • Option C: A client whose diabetes is controlled with oral antidiabetic agents usually doesn’t need to monitor blood glucose levels.
  • Option D: A high carbohydrate diet would exacerbate the client’s condition, particularly if fluid intake is low.

29. Answer: D. Hyperparathyroidism

  • Option D: Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing polyuria.
  • Options A and B: While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don’t have bone pain and increased sleeping.
  • Option C: Hypoparathyroidism is characterized by urinary frequency rather than polyuria.

30. Answer: C. “I’ll take two-thirds of the dose when I wake up and one-third in the late afternoon.”

  • Option C: Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body’s own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.

31. Answer: C. High corticotropin and high cortisol levels

  • Option C: A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels.
  • Options A and D: A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism.
  • Option B: Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.

32. Answer: D. Performing capillary glucose testing every 4 hours

  • Option D: The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia.
  • Option A: Urine ketone testing isn’t indicated because the client does secrete insulin and, therefore, isn’t at risk for ketosis.
  • Option B: Urine specific gravity isn’t indicated because although fluid balance can be compromised, it usually isn’t dangerously imbalanced.
  • Option C: Temperature regulation may be affected by excess cortisol and isn’t an accurate indicator of infection.

33. Answer: C. onset to be at 2:30 p.m. and its peak to be at 4 p.m.

  • Option C: Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

34. Answer: A. No increase in the thyroid-stimulating hormone (TSH) level after 30 minutes during the TSH stimulation test

  • Option A: In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism.
  • Option B: A decreased TSH level indicates a pituitary deficiency of this hormone.
  • Option D: Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

35. Answer: B. “Rotate injection sites within the same anatomic region, not among different regions.”

  • Option B: The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next.
  • Option A: Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations.
  • Option C: Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn’t inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically.
  • Option D: Exercise speeds drug absorption, so the client shouldn’t inject insulin into sites above muscles that will be exercised heavily.

36. Answer: D. Below-normal serum potassium level

  • Option D: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency.
  • Options A and B: An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis.
  • Option C: Metabolic acidosis, not serum alkalosis, may occur in HHNS.

37. Answer: D. Maintaining room temperature in the low-normal range

  • Option D: Graves’ disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client’s room temperature in the low-normal range.
  • Option A: To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids.
  • Option B: Placing extra blankets on the bed of a client with heat intolerance would cause discomfort.
  • Option C: To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

38. Answer: A. Fracture of the distal radius

  • Option A: Colles’ fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It’s most common in women.
  • Options B, C, and D: Colles’ fracture doesn’t refer to a fracture of the olecranon, humerus, or carpal scaphoid.

39. Answer: B. Calcium and phosphorous

  • Option B: In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture.
  • Option D: Sodium and potassium aren’t involved in the development of osteoporosis.

40. Answer: A. Adult respiratory distress syndrome (ARDS)

  • Option A: Severe hypoxia after smoke inhalation is typically related to ARDS.
  • Options B, C, and D: The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.

41. Answer: D. Fat embolism

  • Option D: Long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia.
  • Options A and C: It’s unlikely the client has developed asthma or bronchitis without a previous history.
  • Option B: He could develop atelectasis but it typically doesn’t produce progressive hypoxia.

42. Answer: D. Spontaneous pneumothorax

  • Option D: A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath.
  • Options A and B: An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi.
  • Option C: Pneumonia would have bronchial breath sounds over the area of consolidation.

43. Answer: C. Pneumothorax

  • Options A, B, and D: From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.

44. Answer: C. Serous fluids fill the space and consolidate the region

  • Option C: Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung.
  • Option A: Air can’t be left in the space.
  • Option B: There’s no gel that can be placed in the pleural space.
  • Option D: The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until space is filled.

45. Answer: A. Alveolar damage in the infarcted area

  • Option A: The infarcted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts.
  • Option B: Clot formation usually occurs in the legs.
  • Options C and D: There’s a loss of lung parenchyma and subsequent scar tissue formation.

46. Answer: D. Respiratory alkalosis

  • Option D: A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.

47. Answer: A. Air leak

  • Option A: Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax, an air leak can occur as air is pulled from the pleural space.
  • Options B and C: Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.

48. Answer: B. 21

  • Option B: 3000 x 10 divided by 24 x 60.

49. Answer: B. 2.4 ml

  • Option B: .05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.

50. Answer: D. “I should put on the stockings before getting out of bed in the morning.

  • Option D: Promote venous return by applying external pressure on veins.

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