04 NCLEX PN Practical Nurses Quiz | Practice Test 04

NCLEX PN Practical Nurses Quiz | Practice Test 04

1 >>A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered a sliding scale insulin. The most likely explanation for this order is: ?

• (A) Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.
• (B) Total Parenteral Nutrition cannot be managed with oral hypoglycemics.
• (C) Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.
• (D) Total Parenteral Nutrition leads to further pancreaticdisease.

Solution Total Parenteral Nutrition is a high-glucose solution. This therapy often causes the glucose levels to be elevated. Because this is a common complication,insulin might be ordered. Answer A is incorrect because TPN is used to treat negative nitrogen balance; it will not lead to negative nitrogen balance. Answer B is incorrect because Total Parenteral Nutrition can be managed with oral hypoglycemic drugs, but it is difficult. Answer D is incorrect because Total Parenteral Nutrition will not lead to further pancreatic disease.

2 >>An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for her first check-up. To develop a teaching plan, the nurse should initially assess: ?

• (A) The client's knowledge of the signs of preterm labor
• (B) The client's feelings about the pregnancy
• (C) Whether the client was using a method of birth control
• (D) The client's thought about future children

Solution The client who is 10 weeks pregnant should be assessed to determine how she feels about the pregnancy. Answer A is incorrect because it is too 140 Chapter 2 early to discuss preterm labor. Answer C is incorrect because it is too late to discuss whether she was using a method of birth control. Answer D is incorrect because now is not the time to discuss future children; this can be done after the client delivers

3 >>The client has an order for Demerol (meperidine) and Phenergan (promethazine) to be given together. The nurse is aware that the purpose of this order is: ?

• (A) For its synergistic effect
• (B) For its agonist effect
• (C) For its extrapyramidal effects
• (D) For its antagonistic effects

Solution Demerol and Phenergan are given for their synergistic effect.Synergistic means that one drug increases the effectiveness of the other. Demerol is a narcotic analgesic, and Phenergan is an antianxiety, antiemetic medication. Answer B is incorrect because they are not given for the agonist effect; an agonist is a medication that works with chemicals or substances in the blood, such as hormones. Answer C is incorrect because they are not given together to cause extrapyramidal effects.Answer D is incorrect because antagonists work against one another.

4 >>The physician has ordered a liver scan with contrast to confirm the diagnosis. Before the procedure, the nurse should: ?

• (A) Assess the client for allergies
• (B) Bolus the client with fluid
• (C) Tell the client he will be asleep
• (D) Insert a urinary catheter

Solution A thyroid scan with contrast uses a dye, so the client should be assessed for allergies to iodine. The client will not have a bolus of fluid, will not be asleep, and will not have a urinary catheter inserted, so answers B, C, and D are incorrect

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5 >>The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to: ?

• (A) Provide immunity against Rh isoenzymes
• (B) Prevent the formation of Rh antibodies
• (C) Eliminate circulating Rh antibodies
• (D) Convert the Rh factor from negative to positive

Solution RhoGam is used to prevent formation of Rh antibodies. It does not provide immunity to Rh isoenzymes, eliminate circulating Rh antibodies, or convert the Rh factor from negative to positive, so answers A, C, and D are incorrect.

6 >>The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot? ?

• (A) Application of a short inclusive spica cast
• (B) Stabilization with a plaster-of-Paris cast
• (C) Surgery with Kirschner wire implantation
• (D) No bandages to be used to correct the fractured foot

Solution A client with a fractured foot often has a short leg cast applied to stabilize the fracture. Answer A is incorrect because a spica cast is used to stabilize a fractured pelvis or vertebral fracture. Answer C is incorrect because Kirschner wires are used to stabilize small bones such as toes. Answer D is incorrect because the client will most likely have a cast application.

7 >>A nurse is performing the Trendelenburg test for the client with multiple sclerosis. The nurse is aware that this test is used to measure: ?

• (A) Muscle weakness
• (B) Fluid retention
• (C) Ability to concentrate
• (D) Dexterity

Solution A Trendelenburg test is done to determine muscle weakness. The Trendelenburg sign is positive if the client cannot stand on one leg without having pelvic weakness. The test is not done to determine fluid volume, as stated in answer B, or to determine the client's ability to concentrate, as stated in answer C. Answer D is incorrect because the Trendelenburg test does not check for dexterity.

8 >>Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ? ?

• (A) Antivirals
• (B) Antibiotics
• (C) Immunosuppressants
• (D) Analgesics

Solution Immunosuppressants are used to prevent antibody formation.Answer A is incorrect because antivirals are not used in this client. Answer B is not correct because antibiotics do not prevent organ rejection. Answer D is incorrect because analgesics do not prevent rejection.

9 >>The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use: ?

• (A) Mydriatics to facilitate removal
• (B) Miotic medications such as Timoptic
• (C) A laser to smooth and reshape the lens
• (D) Silicone oil injections into the eyeball

Solution Before cataract removal, the client will have Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens. Answer B is incorrect because miotics constrict the pupil and are not used in cataract clients. Answer C is incorrect because a laser is not used to smooth and reshape the lens. The diseased lens is removed. Answer D is incorrect because a silicone oil is not injected in this client

10 >>A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client? ?

• (A) Placing mirrors in several locations in the home
• (B) Placing a picture of herself in her bedroom
• (C) Placing simple signs to indicate the location of the bedroom, bathroom, and so on
• (D) Alternating healthcare workers to prevent boredom

Solution Answers A and B are not recommended because placing mirrors and pictures in several locations tends to cause agitation. Answer C is correct because placing simple signs that indicate the location of rooms where the client sleeps, eats, and bathes will help the client be more independent. Answer D is incorrect because alternating healthcare workers also confuses the client and leads to further confusion

11 >>A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to: ?

• (A) Prevent the need for dressing changes
• (B) Reduce edema at the incision
• (C) Provide for wound drainage
• (D) Keep the common bile duct open

Solution A Jackson-Pratt drain is a serum-collection device commonly used in abdominal surgery. Answers A, B, and D are incorrect because a Jackson-Pratt Practice Exam 2 and Rationales 141 drain will not prevent the need for dressing changes, reduce edema of the incision, or keep the common bile duct open. A t-tube is used to keep the common bile duct open.

12 >>The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of: ?

• (A) Mongolian spots
• (B) Scrotal rugae
• (C) Head lag
• (D) Vernix caseosa

Solution Head lag is associated with the pre-term newborn and is an expected finding in the newborn less than 36 weeks gestation. Answer A is incorrect because the presence of Mongolian spots are not associated with the pre-term newborn.Answers B and D are findings associated with the full-term newborn, therefore they are incorrect.

13 >>The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately? ?

• (A) Hematuria
• (B) Muscle spasms
• (C) Dizziness
• (D) Nausea

Solution Hematuria in a client with a pelvic fracture can indicate trauma to the bladder or impending bleeding disorders. Answers B, C, and D are incorrect because it is not unusual for the client to complain of muscles spasms, dizziness, or nausea following multiple traumas

14 >>A client is brought to the emergency room by the police. He is combative and yells, "I have to get out of here; they are trying to kill me." Which assessment is most likely correct in relation to this statement? ?

• (A) The client is experiencing an auditory hallucination.
• (B) The client is having a delusion of grandeur.
• (C) The client is experiencing paranoid delusions.
• (D) The client is intoxicated.

Solution The statement "They are trying to kill me" indicates paranoid delusions. There is no data to indicate that the client is hearing voices, as stated in answer A. Delusions of grandeur are fixed beliefs that the client is superior or perhaps a famous person, so answer B is incorrect. There is no data to indicate that the client is intoxicated, so answer D is incorrect.

15 >>The nurse is performing tracheostomy care. If the client coughs out the inner cannula, the nurse should: ?

• (A) Call the doctor
• (B) Replace the inner cannula with a new one
• (C) Hold open the stoma with forceps
• (D) Begin rescue breathing

Solution Because there is an inner and an outer cannula, the nurse should simply replace the old one with a new, sterile one. Answer A is incorrect because there is no need to call the doctor. Answer C is incorrect because there is no need to hold open the stoma because there is an out cannula. Answer D is incorrect because there is no data to support the lack of respirations in the client.

16 >>An infant's Apgar score is 9 at 5 minutes. The nurse is aware that the most likely cause for the deduction of one point is: ?

• (A) The baby is cold.
• (B) The baby is experiencing bradycardia.
• (C) The baby's hands and feet are blue.
• (D) The baby is lethargic.

Solution Infants with a 9 Apgar at 5 minutes most likely have acryocyanosis, a normal physiologic adaptation to birth. Answer A is incorrect because it is most likely not related to the infant being cold. Answer B is incorrect because there is no evidence that the baby has bradycardia. Answer D is incorrect because there is no evidence that the baby is lethargic.

17 >>The primary reason for rapid continuous rewarming of the area affected by frostbite is to: ?

• (A) Lessen the amount of cellular damage
• (B) Prevent the formation of blisters
• (C) Promote movement
• (D) Prevent pain and discomfort

Solution The primary reason for rapid, continuous rewarming of an area affected by frostbite is to lessen cellular damage. Answers B, C, and D are not primary reasons for rapid continuous rewarming, therefore they are incorrect.

18 >>A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by: ?

• (A) Passing water through the dialyzing membrane
• (B) Eliminating plasma proteins from the blood
• (C) Lowering the pH by removing nonvolatile acids
• (D) Filtering waste through a dialyzing membrane

Solution Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. Answer A is incorrect because it does not pass water through a dialyzing membrane. Answer B is not correct because hemodialysis does not eliminate plasma protein from the blood. Answer C is incorrect because it does not lower the pH

19 >>During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate? ?

• (A) Administering an antibiotic
• (B) Contacting the physician for an order for immune globulin
• (C) Administering an antiviral
• (D) Telling the client that he should remain in isolation for 2 weeks

Solution The client who is immune-suppressed and exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client, so answers A and C are incorrect. Answer D is incorrect because it is too late to place the client in isolation

20 >>A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact? ?

• (A) The client should be placed in a room with negative pressure.
• (B) Infection requires close contact; therefore, the door may remain open.
• (C) Transmission is highly likely, so the client should wear a mask at all times.
• (D) Infection requires skin-to-skin contact and is prevented by handwashing, gloves, and a gown.

Solution The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid, or by touch to the skin of the client. MRSA is cultured from the nasal passages of the client, so the client should be instructed to cover the nose and mouth when he sneezes or coughs. Answer C is 142 Chapter 2 incorrect because it is not necessary for the client to wear the mask at all times. The nurse should wear the mask.

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