05 NCLEX PN Practical Nurses Quiz | Practice Test 05

NCLEX PN Practical Nurses Quiz | Practice Test 05

1 >>A client with an above-the-knee amputation is being taught methods to prevent hip-flexion deformities. Which instruction should be given to the client? ?

• (A) "Lie supine with the head elevated on two pillows."
• (B) "Lie prone every 4 hours during the day for 30 minutes."
• (C) "Lie on your side with your head elevated."
• (D) "Lie flat during the day."

Solution To prevent hip-flexion deformities, the client should be instructed to lie prone every 4 hours for 30 minutes during the day. This will force the leg to extend to 0 and prevent the contracture. Answer A, C, and D are incorrect because lying on his back or side, or flat will not help.

2 >>A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that, during the Whipple procedure, the doctor will remove the: ?

• (A) Head of the pancreas
• (B) Proximal third section of the small intestines
• (C) Stomach and duodenum
• (D) Esophagus and jejunum

Solution During a Whipple procedure, the head of the pancreas, a portion of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and the esophagus also is not removed, as in answer D

3 >>The physician has ordered a minimal bacteria diet for a client with neutropenia. The client should be taught to avoid eating: ?

• (A) Fruits
• (B) Salt
• (C) Pepper
• (D) Ketchup

Solution Pepper is not processed and contains bacteria. Answer A is incorrect because fruits can be eaten; they should be cooked or washed and peeled.Answers B and D are allowed.

4 >>A client is discharged home with a prescription for Coumadin (warfarin sodium). The client should be instructed to: ?

• (A) Have a Protime done monthly
• (B) Eat more fruits and vegetables
• (C) Drink more liquids
• (D) Avoid crowds

Solution Coumadin (sodium warfarin) is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Answer B is incorrect because eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K that increases clotting. Answer C is incorrect because drinking more liquids is not necessary. Answer D is not correct because avoiding crowds is also not necessary.

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5 >>The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to: ?

• (A) Perform the Valsalva maneuver as the catheter is advanced
• (B) Turn his head to the left side and hyperextend the neck
• (C) Take slow, deep breaths as the catheter is removed
• (D) Turn his head to the right while maintaining a sniffing position

Solution The client having removal of a central venous catheter should be told to hold his breath and bear down. This is known as the Valsalva maneuver. This prevents air from entering the line. Answers B, C, and D are incorrect because they will not facilitate removal.

6 >>A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for: ?

• (A) Allergies to pineapples and bananas
• (B) A history of streptococcal infections
• (C) Prior therapy with phenytoin
• (D) A history of alcohol abuse

Solution Clients with a history of streptococcal infections might have antibodies that render the streptokinase ineffective. Answer A is incorrect because there is no reason to assess the client for allergies to pineapples or bananas. There is no correlation to the use of phenytoin and streptokinase, so answer C is incorrect. A history of alcohol abuse is also not a factor in the order for streptokinase, so answer D is incorrect.

7 >>The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid: ?

• (A) Using oil- or cream-based soaps
• (B) Flossing between the teeth
• (C) The intake of salt
• (D) Using an electric razor

Solution The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth. Answer A is incorrect because using oils and cream-based soaps is allowed. Answer C is incorrect because the client can eat salt. An electric razor is the best way to shave, so answer D is incorrect.

8 >>The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to: ?

• (A) Apply the new tie before removing the old one
• (B) Have a helper present
• (C) Hold the tracheotomy with the nondominant hand while removing the old tie
• (D) Ask the doctor to suture the tracheotomy in place

Solution The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Answer B is not enough action. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Answer D is incorrect because asking the doctor to suture the tracheotomy in place is not appropriate.

9 >>The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to: ?

• (A) Turning the client to the left side
• (B) Milking the tube to ensure patency
• (C) Slowing the intravenous infusion
• (D) Notifying the physician

Solution The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A is incorrect because turning the client to the left side will not help. Milking the tube is done only with an order and will not help in this Practice Exam 2 and Rationales 143 situation, so answer B is incorrect. Slowing the intravenous infusion is inappropriate. The infusion should be increased, so answer C is incorrect

10 >>The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication? ?

• (A) Digoxin
• (B) Epinephrine
• (C) Aminophyline
• (D) Atropine

Solution The infant with tetrology of falot has five heart defects. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client, so answers B, C, and D are incorrect.

11 >>The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will: ?

• (A) Tire easily
• (B) Grow normally
• (C) Need more calories
• (D) Be more susceptible to viral infections

Solution The toddler with a ventricular septal defect will tire easily. Answer B is incorrect because he will be small for his age. He will not need more calories, so answer C is incorrect. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children, so answer D is incorrect

12 >>A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test: ?

• (A) Determines the lung maturity of the fetus
• (B) Measures the activity of the fetus
• (C) Shows the effect of contractions on fetal heart rate
• (D) Measures the neurological well-being of the fetus

Solution A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological wellbeing, so answers A, C, and D are incorrect

13 >>The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as: ?

• (A) Atrial flutter
• (B) A sinus rhythm
• (C) Ventricular tachycardia
• (D) Atrial fibrillation

Solution The graft indicates ventricular tachycardia. The others are not noted on the ECG strip, so answers A, B, and D are incorrect. 144 Chapter 2

14 >>A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should: ?

• (A) Be injected into the deltoid muscle
• (B) Be injected in the abdomen
• (C) Aspirate after the injection
• (D) Clear the air from the syringe before injections

Solution Answer A is incorrect because Lovenox injections should be given in the abdomen. Answers C and D are incorrect because the client should not aspirate after the injection or clear the air from the syringe before injection.

15 >>The nurse has a pre-op order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to: ?

• (A) Administer the medications together in one syringe
• (B) Administer the medications separately
• (C) Administer the Valium, wait 5 minutes, and administer the Phenergan
• (D) Question the order because they cannot be given to the same client

Solution Answer A is incorrect because Valium (diazepam) is not administered with other medications. Both medications can be given to the same client, so answer D is incorrect. Answer C is not necessary, therefore is incorrect.

16 >>A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to: ?

• (A) Douche after intercourse
• (B) Void every 3 hours
• (C) Obtain a urinalysis monthly
• (D) Wipe from back to front after voiding

Solution Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Answer A is incorrect because douching is not recommended. Answer C is incorrect because obtaining a urinalysis monthly is not necessary. Answer D is incorrect because the client should practice wiping from front to back after voiding and bowel movements.

17 >>Which task should be assigned to the nursing assistant? ?

• (A) Placing the client in seclusion
• (B) Emptying the Foley catheter of the preeclamptic client
• (C) Feeding the client with dementia
• (D) Ambulating the client with a fractured hip

Solution Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. An RN or the physician can place the client in seclusion, so answer A is incorrect. Answer B is incorrect because the nurse should empty the Foley catheter of the preeclamptic client because the client is unstable. Answer D is incorrect because a nurse or physical therapist should ambulate the client with a fractured hip.

18 >>The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? ?

• (A) A tracheotomy set
• (B) A padded tongue blade
• (C) An endotracheal tube
• (D) An airway

Solution The client who has recently had a thyroidectomy is at risk for tracheal edema. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D will not work. A padded tongue blade is used for seizures and is not used for the client with tracheal edema, so answer D is incorrect.

19 >>A client hospitalized with severe depression and suicidal ideation refuses to talk with the nurse. The nurse recognizes that the suicidal client has difficulty: ?

• (A) Expressing feelings of low self-worth
• (B) Discussing remorse and guilt for actions
• (C) Displaying dependence on others
• (D) Expressing anger toward others

Solution The suicidal client has difficulty expressing anger toward others. The depressed suicidal client frequently expresses feelings of low self-worth, feelings of remorse and guilt, and a dependence on others; therefore, answers A, B, and C are incorrect.

20 >>A client receiving HydroDIURIL (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is: ?

• (A) Pear
• (B) Apple
• (C) Orange
• (D) Banana

Solution Answers A, B, and C are incorrect because they contain lower amounts of potassium. (Note that the banana contains 450mg K+, the orange contains235mg K+, the pear contains 208mg K+, and the apple contains 165mg K+.)

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