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NCLEX-RN Practice Quiz Test Bank 4 75
Questions And Answers 2024 update
1. 1. Question Which action(s) should you delegate to the experienced nursing assistant when caring for a patient with a thrombotic stroke with residual left-sided weakness? Select all that apply. o A. Assist the patient to reposition every 2 hours. o B. Reapply pneumatic compression boots. o C. Remind the patient to perform active ROM. o D. Check extremities for redness and edema. Incorrect Correct Answer: A, B, & C. The experienced nursing assistant would know how to reposition the patient and how to reapply compression boots and would remind the patient to perform activities he has been taught to perform. Option D: Assessing for redness and swelling (signs of deep venous thrombosis {DVT}) requires additional education and is still appropriate to the professional nurse. 2. 2. Question The patient who had a stroke needs to be fed. What instruction should you give to the nursing assistant who will feed the patient? A. Position the patient sitting up in bed before you feed her. B. Check the patient’s gag and swallowing reflexes. C. Feed the patient quickly because there are three more waiting. D. Suction the patient’s secretions between bites of food. Incorrect Correct Answer: A. Position the patient sitting up in bed before you feed her. Positioning the patient in a sitting position decreases the risk of aspiration. Option B: The nursing assistant is not trained to assess gag or swallowing reflexes. Option C: The patient should not be rushed during feeding.
Option D: A patient who needs to be suctioned between bites of food is not handling secretions and is at risk for aspiration. This patient should be assessed further before feeding.
3. 3. Question You have just admitted a patient with bacterial meningitis to the medical-surgical unit. The patient complains of a severe headache with photophobia and has a temperature of 102.60 F orally. Which collaborative intervention must be accomplished first? A. Administer codeine 15 mg orally for the patient’s headache. B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever. D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure. Incorrect Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection. Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid antibiotic treatment is essential. Option A: Pain medications may be given after treating the infection that is most probably causing it. Option C: Acetaminophen should be given to decrease the fever after administering the antibiotics first. Option D: Furosemide will help reduce CNS stimulation and irritation and should be implemented as soon as possible. 4. 4. Question You are mentoring a student nurse in the intensive care unit (ICU) while caring for a patient with meningococcal meningitis. Which action by the student requires that you intervene immediately? A. The student enters the room without putting on a mask and gown. B. The student instructs the family that visits are restricted to 10 minutes. C. The student gives the patient a warm blanket when he says he feels cold. D. The student checks the patient’s pupil response to light every 30 minutes. Incorrect Correct Answer: A. The student enters the room without putting on a mask and gown.
While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure? A. Place the patient on a non-rebreather mask will the oxygen at 15 L/minute. B. Administer lorazepam (Ativan) 1 mg IV. C. Turn the patient to the side and protect the airway. D. Assess level of consciousness during and immediately after the seizure. Incorrect Correct Answer: C. Turn the patient to the side and protect the airway. The priority action during a generalized tonic-clonic seizure is to protect the airway. Option B: Administration of lorazepam should be the next action since it will act rapidly to control the seizure. Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea. Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness.
7. 7. Question A patient recently started on phenytoin (Dilantin) to control simple complex seizures is seen in the outpatient clinic. Which information obtained during his chart review and assessment will be of greatest concern? A. The gums appear enlarged and inflamed. B. The white blood cell count is 2300/mm3. C. Patient occasionally forgets to take the phenytoin until after lunch. D. Patient wants to renew his driver’s license next month. Incorrect Correct Answer: B. The white blood cell count is 2300/mm3. Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication. Option A: Inflammation of the gums should be reported to the physician, but it does not require immediate attention.
Option C: The nurse should include in the patient teaching the importance of taking medications on time to avoid episodes of seizure. Option D: Driving is prohibited for a client with a seizure disorder. This should be included in the patient’s teaching, but will not require a change in medical treatment for the seizures.
8. 8. Question After receiving a change-of-shift report at 7:00 AM, which of these patients will you assess first? A. A 23-year-old with a migraine headache who is complaining of severe nausea associated with retching. B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching. C. A 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast. D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Incorrect Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral temperature of 101.80 F and flank pain. Urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly. Option A: This patient needs further assessment, but does not require immediate attention. A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities. Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done. Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.
Correct Answer: A. Check for improvement in resident memory after medication therapy is initiated. LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Option B: Assessment for changes on the Mini-Mental State Examination is an RN responsibility. Option C: Assisting residents with personal care and hygiene would be delegated to nursing assistants working in the LTC facility. Option D: Developing an activity plan should be done by an RN.
11. 11. Question An 89-year-old female patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer’s disease. The patient’s husband reports to you that he rarely gets a good night’s sleep because he needs to make sure his wife does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient? A. Decreased Cardiac Output related to poor myocardial contractility B. Caregiver Role Strain related to continuous need for providing care C. Ineffective Therapeutic Regimen Management related to poor patient memory D. Risk for Falls related to patient wandering behavior during the night Incorrect Correct Answer: B. Caregiver Role Strain related to continuous need for providing care The husband’s statement about lack of sleep and anxiety over whether the patient is receiving the correct medications are behaviors that support this diagnosis. Option A: There is no evidence that the patient’s cardiac output is decreased. Alzheimer?s disease and HF often occur together and thus increase the cost of care and health resource utilization; this highlights the need to investigate the relationship between these two conditions. Impaired cognition in HF patients leads to significantly more frequent hospital readmissions and increases mortality rates. Option C: Ineffective Therapeutic Regimen Management is not a priority as based on the statement. Option D: Risk for falls is not the priority at this time. Falls are a leading cause of broken hips and other serious injuries in the elderly, and those with Alzheimer’s are at particularly high risk of falling. Problems with vision, perception, and balance increase as Alzheimer’s advances, making the risk of a fall more likely.
12. 12. Question You are caring for a patient with recurrent glioblastoma who is receiving dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns you the most? A. The patient does not recognize family members. B. The blood glucose level is 234 mg/dL. C. The patient complains of a continued headache. D. The daily weight has increased 1 kg. Incorrect Correct Answer: A. The patient does not recognize family members. The inability to recognize a family member is a new neurologic deficit for this patient, and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the physician immediately so that treatment can be initiated. Option B: Increased blood glucose levels is an expected side effect but not an emergency. Option C: The continued headache also indicates that the ICP may be elevated, but it is not a new problem. Option D: The weight gain is a common adverse effect of dexamethasone that may require treatment, but is not an emergency. 13. 13. Question A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterward.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first? A. Place on the hospital alcohol withdrawal protocol. B. Transfer to radiology for a CT scan. C. Insert a retention catheter to straight drainage. D. Give phenytoin (Dilantin) 100 mg PO. Incorrect Correct Answer: B. Transfer to radiology for a CT scan.
B. Anxiety related to change in or threat to health status C. Hopelessness related to deteriorating physiological condition D. Risk for Side effects related to medical therapy Incorrect Correct Answer: A. Acute pain related to biologic and chemical factors The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management. Option B: Anxiety is a correct diagnosis, but it is not the priority. Tension headaches are common for people that struggle with severe anxiety or anxiety disorders. Tension headaches can be described as a heavy head, migraine, head pressure, or feeling like there is a tight band wrapped around their head. These headaches are due to a tightening of the neck and scalp muscles. Option C: Hopelessness should be addressed as part of the nursing care plan, but it does not require urgency. Hopelessness can result when someone is going through difficult times or unpleasant experiences. A person may feel overwhelmed, trapped, or insecure, or may have a lot of self-doubts due to multiple stresses and losses. He or she might think that challenges are unconquerable or that there are no solutions to the problems and may not be able to mobilize the energy needed to act on his or her own behalf. Option D: The risk for side effects is accurate, but it is not as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization
16. 16. Question Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is: A. Green liquid B. Solid formed C. Loose, bloody D. Semiformed Incorrect Correct Answer: C. Loose, bloody Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.
Option A: Food, medicines, and other things ingested can affect the consistency or color of the stool. Option B: A formed stool may occur a week after the surgery. Option D: The stool from a colostomy can be thin or thick liquid, or semiformed.
17. 17. Question Where would nurse Kristine place the call light for a male client with a right-sided brain attack and left homonymous hemianopsia? A. On the client’s right side B. On the client’s left side C. Directly in front of the client D. Where the client like Incorrect Correct Answer: A. On the client’s right side The client has left visual field blindness. The client will see only from the right side. Homonymous hemianopsia is a condition in which a person sees only one side?right or left?of the visual world of each eye. The person may not be aware that the vision loss is happening in both eyes, not just one. An injury to the right part of the brain produces loss of the left side of the visual world of each eye. Option B: The client would not be able to see the call light on his right side because he can only see the left side. Option C: Only the right half of the visual world can be seen by the client. Option D: The most ideal place to put the call light is on the client’s right side to avoid any injuries. 18. 18. Question A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? A. Check respiration, circulation, neurological response B. Align the spine, check pupils, and check for hemorrhage C. Check respirations, stabilize the spine, and check the circulation D. Assess level of consciousness and circulation Incorrect
A. Call for help and note the time B. Clear the airway C. Give two sharp thumps to the precordium and check the pulse D. Administer two quick blows Incorrect Correct Answer: A. Call for help and note the time Having established, by stimulating the client, that the client is unconscious rather than sleep, the nurse should immediately call for help. This may be done by dialing the operator from the client’s phone and giving the hospital code for cardiac arrest and the client’s room number to the operator, or if the phone is not available, by pulling the emergency call button. Noting the time is important baseline information for cardiac arrest procedures. Option B: A patent airway has been established the moment the nurse declares that the client is unconscious and calls for help. Option C: This action can be done if there is an unwitnessed, unmonitored, unstable ventricular tachycardia when a defibrillator is not immediately available. Option D: Administering two quick blows to the precordium is less effective and its use is more limited ideally.
21. 21. Question Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The nurse should: A. Plan care so the client can receive 8 hours of uninterrupted sleep each night. B. Monitor vital signs every 2 hours. C. Make sure that the client takes food and medications at prescribed intervals. D. Provide milk every 2 to 3 hours. Incorrect Correct Answer: C. Make sure that the client takes food and medications at prescribed intervals. Food and drug therapy will prevent the accumulation of hydrochloric acid or will neutralize and buffer the acid that does accumulate. Option A: Uninterrupted sleep for 8 hours is good, but it does not directly affect the production of acid.
Option B: Monitoring vital signs every 2 hours is unnecessary. It can be monitored every shift or every 4 hours. Option D: Milk could aggravate the production of hydrochloric acid. The nutrients in milk, particularly fat, may stimulate the stomach to produce more acid.
22. 22. Question A male client was on warfarin (Coumadin) before admission and has been receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68 seconds. What should Nurse Carla do? A. Stop the I.V. infusion of heparin and notify the physician. B. Continue treatment as ordered. C. Expect the warfarin to increase the PTT. D. Increase the dosage, because the level is lower than normal. Incorrect Correct Answer: B. Continue treatment as ordered. The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the therapeutic level is 1. to 2 times the normal level. Option A: There is no need to stop the infusion since the PTT is at a therapeutic level. In patients receiving concomitant heparin and warfarin therapy, PTT reflects the combined effects of both drugs. Because of the marked effect of warfarin on the PTT, decreasing heparin dose in response to a high PTT frequently results in subtherapeutic heparin levels. Option C: The PTT is not used to monitor warfarin therapy, but PTT may be prolonged by warfarin at high doses. Option D: The level is correct; increasing the dosage is unnecessary. Warfarin markedly affects PTT, for each increase of 1.0 in the international normalized ratio, the PTT increases 16 seconds. 23. 23. Question A client underwent ileostomy, when should the drainage appliance be applied to the stoma? A. 24 hours later, when edema has subsided B. In the operating room C. After the ileostomy begins to function D. When the client is able to begin self-care procedures
25. 25. Question While monitoring a male client several hours after a motor vehicle accident, which assessment data suggest increasing intracranial pressure? A. Blood pressure has decreased from 160/90 to 110/70. B. Pulse is increased from 87 to 95, with an occasional skipped beat. C. The client is oriented when aroused from sleep and goes back to sleep immediately. D. The client refuses dinner because of anorexia. Incorrect Correct Answer: C. The client is oriented when aroused from sleep and goes back to sleep immediately. This finding suggests that the level of consciousness is decreasing. Option A: A blood pressure level of 110/70 mmHg is within normal limits. Increased intracranial pressure is caused by an increase in blood pressure. Option B: A pulse rate of 95 bpm is within the normal range. When arterial blood pressure exceeds the intracranial pressure, blood flow to the brain is restored. The increased arterial blood pressure caused by the CNS ischemic response stimulates the baroceptors in the carotid bodies, thus slowing the heart rate drastically often to the point of bradycardia. Option D: Anorexia is not related to increased intracranial pressure. Anorexia is an eating disorder characterized by abnormally low body weight, an intense fear of gaining weight, and a distorted perception of weight. 26. 26. Question Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following symptoms may appear first? A. Altered mental status and dehydration B. Fever and chills C. Hemoptysis and Dyspnea D. Pleuritic chest pain and cough Incorrect Correct Answer: A. Altered mental status and dehydration
Elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response. Option B: Fever and chills are classic signs of pneumonia that may appear later in the elderly. The inflammatory response results in a proliferation of neutrophils. This can damage lung tissue, leading to fibrosis and pulmonary edema, which also impairs lung expansion. Option C: Hemoptysis is a late sign of pneumonia. Bleeding in the lungs may originate from bronchial arteries, pulmonary arteries, bronchial capillaries, and alveolar capillaries. Dyspnea may occur early, especially among the elderly. Swelling and mucus can make it harder to move air through the airways, making it harder to breathe. This leads to shortness of breath, difficulty of breathing, and feeling more tired than normal. Option D: Cough and pleuritic chest pain are the common symptoms of pneumonia. The air sacs may fill with fluid or pus, causing cough with phlegm or ous, fever, chills, and difficulty breathing.
27. 27. Question A male client has active tuberculosis (TB). Which of the following symptoms will be exhibited? A. Chest and lower back pain B. Chills, fever, night sweats, and hemoptysis C. Fever of more than 104°F (40°C) and nausea D. Headache and photophobia Incorrect Correct Answer: B. Chills, fever, night sweats, and hemoptysis Typical signs and symptoms are chills, fever, night sweats, and hemoptysis. Option A: Chest pain may be present from coughing but isn’t usual. Pleurisy is a condition where there is inflammation or irritation of the lining of the lungs and chest. There is a sharp pain felt when breathing, coughing, or sneezing. Option C: Clients with TB typically have low-grade fevers, not higher than 102°F (38.9°C). Fever typically develops in the late afternoon or evening in 68% of the cases, and this typical fever is significantly more common in patients less 60 years of age. Option D: Nausea, headache, and photophobia aren’t usual TB symptoms. Typical symptoms include a cough that lasts for more than 3 weeks, loss of appetite and unintentional weight loss, fever, chills, and night sweats. 28. 28. Question
Option A: The client’s respiratory system is most likely being suppressed, so an acute asthma attack would be unlikely. In an asthma attack, the airways become swollen and inflamed. The muscles around the airways contract and the airways produce extra mucus, causing the breathing (bronchial) tubes to narrow. Option C: A seizure is not likely to occur in the situation. Seizures are mostly caused by paroxysmal discharges from groups of neurons, which arise as a result of excessive excitation or loss of inhibition. Option D: The client’s respiratory rate is too low and she might be going into a respiratory arrest. Respiratory depression happens when the lungs fail to exchange carbon dioxide and oxygen efficiently. This dysfunction leads to a buildup of carbon dioxide in the body, which can result in health complications.
30. 30. Question A 77-year-old male client is admitted for elective knee surgery. Physical examination reveals shallow respirations but no sign of respiratory distress. Which of the following is a normal physiologic change related to aging? A. Increased elastic recoil of the lungs B. Increased number of functional capillaries in the alveoli C. Decreased residual volume D. Decreased vital capacity Incorrect Correct Answer: D. Decreased vital capacity Reduction in vital capacity is a normal physiologic change including decreased elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an increase in residual volume. Option A: Elastic recoil in the lungs of the elderly are decreased. There is homogenous degeneration of the elastic fibers around the alveolar duct starting around 0 years of age resulting in enlargement of air spaces. Option B: There are fewer functional capillaries in the alveoli as one ages. The alveoli can lose their shape and become baggy. Option C: Decreases in the measures of lung function such as the vital capacity occurs as part of the age-related changes. 31. 31. Question Nurse John is caring for a male client receiving lidocaine I.V. Which factor is the most relevant to the administration of this medication?
A. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter B. Increase in systemic blood pressure C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor D. Increase in intracranial pressure (ICP) Incorrect Correct Answer: C. Presence of premature ventricular contractions (PVCs) on a cardiac monitor. Lidocaine drips are commonly used to treat clients whose arrhythmias haven’t been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. Option A: This should be reported to the physician but it is not the priority in this situation. Option B: An increase in the blood pressure is also significant, but does not need immediate attention. Option D: Increase in ICP is an important factor but isn’t as significant as PVCs in the situation.
32. 32. Question Nurse Ron is caring for a male client taking an anticoagulant. The nurse should teach the client to: A. Report incidents of diarrhea B. Avoid foods high in vitamin K C. Use a straight razor when shaving D. Take aspirin for pain relief Incorrect Correct Answer: B. Avoid foods high in vitamin K The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. Option A: The client may need to report diarrhea but it doesn’t have the effect of taking an anticoagulant. Option C: An electric razor-not a straight razor-should be used to prevent cuts that cause bleeding.
