02 NCLEX PN Practical Nurses Quiz | Practice Test 02

NCLEX PN Practical Nurses Quiz | Practice Test 02

1 >>A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8cm dilated withcomplete effacement. The priority nursing diagnosis at this time is: ?

• (A) Alteration in coping related to pain
• (B) Potential for injury related to precipitate delivery
• (C) Alteration in elimination related to anesthesia
• (D) Potential for fluid volume deficit related to NPO status

Solution Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, so answers C and D are incorrect.

2 >>The client with varicella will most likely have an order for which category of medication? ?

• (A) Antibiotics
• (B) Antipyretics
• (C) Antivirals
• (D) Anticoagulants

Solution Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants, so answers A and D are incorrect. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone; thus, answer B is incorrect

3 >>A client is admitted with complaints of chest pain. Which of the following drug orders should the nurse question? ?

• (A) Nitroglycerin
• (B) Ampicillin
• (C) Propranolol
• (D) Verapamil

Solution Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil, so answers A, C, and D are incorrect. There is no indication for an antibiotic such as ampicillin.

4 >>Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? ?

• (A) Avoid exercise because it fatigues the joints.
• (B) Take prescribed anti-inflammatory medications with meals.
• (C) Alternate hot and cold packs to affected joints.
• (D) Avoid weight-bearing activity.

Solution Clients with rheumatoid arthritis should exercise, but not to the point of pain and not when inflammation is present, so answer A is incorrect. Antiinflammatory drugs should be taken with meals because they cause stomach upset. Alternating heat and cold is not necessary, so answer C is incorrect. Warm, moist soaks are useful to decrease pain. Weight-bearing activities such as walking are useful, so answer D is incorrect.

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5 >>A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should the nurse question? ?

• (A) Meperidine
• (B) Mylanta
• (C) Cimetadine
• (D) Morphine

Solution Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine can be taken by the client with pancreatitis, so answers A, B, and C are incorrect. 136 Chapter 2

6 >>The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because: ?

• (A) Hallucinogenic drugs create both stimulant and depressant effects.
• (B) Hallucinogenic drugs induce a state of altered perception.
• (C) Hallucinogenic drugs produce severe respiratory depression.
• (D) Hallucinogenic drugs induce rapid physical dependence.

Solution Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answer A is incorrect because hallucinogenic drugs don't create both stimulant and depressant effects. Answer C is incorrect because these drugs do not produce severe respiratory depression. Answer D is incorrect because these drugs produce psychological dependence rather than physical dependence.

7 >>A client with a history of abusing barbiturates abruptly stops drug use. The nurse should give priority to assessing the client for: ?

• (A) Depression and suicidal ideation
• (B) Tachycardia and diarrhea
• (C) Muscle cramping and abdominal pain
• (D) Tachycardia and euphoric mood

Solution Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Answer A is incorrect because depression and suicidal ideation go along with barbiturate use. Muscle cramps and abdominal pain are vague symptoms; therefore, answer C is incorrect. Tachycardia is associated with stopping barbiturates, but euphoria is not; thus, answer D is incorrect

8 >>During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position? ?

• (A) Right breech presentation
• (B) Right occipital anterior presentation
• (C) Left sacral anterior presentation
• (D) Left occipital transverse presentation

Solution The fetal heart tones are heard in the upper abdomen. The positions in answers B, C, and D would lead to the presence of fetal heart tones being detected in the lower abdomen. In answer C, the sacrum is the back. This would lead to fetal heart tones being heard above the umbilicus, but on the right side, not the left.

9 >>The primary physiological alteration in the development of asthma is: ?

• (A) Bronchiolar inflammation and dyspnea
• (B) Hypersecretion of abnormally viscous mucus
• (C) Infectious processes causing mucosal edema
• (D) Spasm of bronchiolar smooth muscle

Solution Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there the production is abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma.

10 >>A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should: ?

• (A) Serve high-calorie foods that she can carry with her
• (B) Encourage her appetite by sending out for her favorite foods
• (C) Serve her small, attractively arranged portions
• (D) Allow her in the unit kitchen for extra food whenever she pleases

Solution The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated just as other clients are. Answer C is incorrect because small meals are not correct as an option for this client. Also, in answer D, allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed.

11 >>To maintain Bryant's traction, the nurse must make certain that the child's: ?

• (A) Hips are resting on the bed with the legs suspended at a right angle to the bed
• (B) Hips are slightly elevated above the bed and the legs suspended at a right angle to the bed
• (C) Hips are elevated above the level of the body on a pillow and the legs suspended parallel to the bed
• (D) Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

Solution Bryant's traction is used for fractured femurs and dislocated hips. The hips should be elevated 15� off the bed. Answer A is incorrect because the hips should not be resting on the bed. Answer C is incorrect because the hips should not be above the level of the body. Answer D is incorrect because the hips should not be flat on the bed.

12 >>Which action by the nurse indicates understanding of herpes zoster? ?

• (A) The nurse covers the lesions with a sterile dressing.
• (B) The nurse wears gloves when providing care.
• (C) The nurse administers a prescribed antibiotic.
• (D) The nurse administers oxygen.

Solution Herpes zoster is shingles. Clients with shingles should be placed in contact precautions. Wearing gloves during care will prevent transmission of the virus. Covering the lesions with a sterile gauze is not necessary, so answer A is incorrect. Antibiotics are not prescribed for herpes zoster, so answer C is incorrect. Answer D is incorrect because oxygen is not necessary

13 >>The client has an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that the nurse should contact the lab in order for them to collect the blood: ?

• (A) 15 minutes after the infusion
• (B) 30 minutes before the infusion
• (C) 1 hour after the infusion
• (D) 2 hours after the infusion

Solution A trough level should be drawn 30 minutes before the third or fourth dose. Answers A, C, and D are incorrect times to draw blood levels.

14 >>The client using a diaphragm should be instructed to: ?

• (A) Refrain from keeping the diaphragm in longer than 4 hours
• (B) Keep the diaphragm in a cool location
• (C) Have the diaphragm resized if she gains 5 pounds
• (D) Have the diaphragm resized if she has any surgery

Solution The client using a diaphragm should keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours, not 4, so answer A is incorrect. She should have the diaphragm resized when she gains or loses 10 pounds, so answer C is incorrect.Answer D is incorrect because the client should be resized if she has abdominal surgery. Practice Exam 2 and Rationales 137

15 >>The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client's statements indicates the need for additional teaching? ?

• (A) "I'm wearing a support bra."
• (B) "I'm expressing milk from my breast."
• (C) "I'm drinking four glasses of fluid during a 24-hour period."
• (D) "While I'm in the shower, I'll allow the water to run over my breasts."

Solution Mothers who plan to breastfeed should drink plenty of liquids. Four glasses in a 24-hour period is not enough. Wearing a support bra is a good practice for the mother who is breastfeeding as well as the mother who plans to bottle feed, so answer A is incorrect. Expressing milk from the breast will stimulate milk production, so answer B is incorrect. Answer D is incorrect because allowing the water to run over the breast will also facilitate "letdown," when the milk begins to be produced.

16 >>Damage to the VII cranial nerve results in: ?

• (A) Facial pain
• (B) Absence of ability to smell
• (C) Absence of eye movement
• (D) Tinnitus

Solution The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. Answer B is incorrect because the olfactory nerve is responsible for smell. Answer D is incorrect because the auditory nerve is responsible for hearing loss and tinnitus. Answer C is incorrect because eye movement is controlled by the Trochear or C IV.

17 >>A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication can: ?

• (A) Cause diarrhea
• (B) Change the color of her urine
• (C) Cause mental confusion
• (D) Cause changes in taste

Solution Clients taking Pyridium should be taught that the medication will turn the urine orange or red. Answers A, C, and D are incorrect because this drug does not cause diarrhea, mental confusion, or changes in taste. Pyridium can cause a yellowish color to skin and sclera if taken in large doses

18 >>Which of the following test should be performed before beginning a prescription of Accutane? ?

• (A) Check the calcium level
• (B) Perform a pregnancy test
• (C) Monitor apical pulse
• (D) Obtain a creatinine level

Solution Accutane is contraindicated for use by pregnant clients because it causes teratogenic effects. Answers A, C, and D are incorrect because calcium levels, apical pulse, and creatinine levels are not necessary

19 >>A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir? ?

• (A) Limiting the client's activity
• (B) Encouraging a high-carbohydrate diet
• (C) Utilizing an incentive spirometer to improve respiratory function
• (D) Encouraging fluids

Solution Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Answer A is incorrect because there is no need to limit activity. Answer B is incorrect because there is no need to encourage a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir, so answer C is incorrect

20 >>A client is admitted for an MRI (magnetic resonance imaging). The nurse should question the client regarding: ?

• (A) Hearing loss
• (B) A titanium hip replacement
• (C) Allergies to antibiotics
• (D) Inability to move his feet

Solution The client will be asked to remain still during portions of the exam. If the client has difficulty hearing, accommodations for the inability to follow instructions will need to be made. Answer B is incorrect because clients with a titanium joint replacement can have an MRI (magnetic resonance imaging). Answer C is incorrect because the client will not have ntibiotics administered in preparation for the exam. Answer D is incorrect because the client will not need to move his feet during the exam

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