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06/18/2013

NCLEX Question & Answer Part 1 1. A patient tells you that her urine is starting to look discolored.

If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration? a. Sulfasalazine b. Levodopa c. Phenolphthalein d. Aspirin 2. You are responsible for reviewing the nursing unit’s refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator’s contents? a. Corgard b. Humulin (injection) c. Urokinase d. Epogen (injection) 3. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? a. IgA b. IgD c. IgE d. IgG 4. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take? a. Immediately see a social worker b. Start prophylactic AZT treatment c. Start prophylactic Pentamide treatment d. Seek counseling 5. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? a. Atherosclerosis b. Diabetic nephropathy c. Autonomic neuropathy d. Somatic neuropathy 6. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect? a. Multiple sclerosis b. Anorexia nervosa c. Bulimia d. Systemic sclerosis 7. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect? a. Diverticulosis b. Hypercalcaemia c. Hypocalcaemia d. Irritable bowel syndrome 8. Rho gam is most often used to treat____ mothers that have a ____ infant. a. RH positive, RH positive b. RH positive, RH negative

c. RH negative, RH positive d. RH negative, RH negative 9. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU? a. A Guthrie test can check the necessary lab values. b. The urine has a high concentration of phenylpyruvic acid c. Mental deficits are often present with PKU. d. The effects of PKU are reversible. 10. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient? a. Onset of pulmonary edema b. Metabolic alkalosis c. Respiratory alkalosis d. Parkinson’s disease type symptoms 11. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is? a. Let others know about the patient’s deficits b. Communicate with your supervisor your concerns about the patient’s deficits. c. Continuously update the patient on the social environment. d. Provide a secure environment for the patient. 12. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient? a. Deep breathing techniques to increase O2 levels. b. Cough regularly and deeply to clear airway passages. c. Cough following bronchodilator utilization d. Decrease CO2 levels by increase oxygen take output during meals. 13. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present? a. Slow pulse rate b. Weight gain c. Decreased systolic pressure d. Irregular WBC lab values 14. A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome? a. Simian crease b. Brachycephaly c. Oily skin d. Hypotonicity 15. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered? a. Streptokinase b. Atropine c. Acetaminophen d. Coumadin 16. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids?” a. Green vegetables and liver

b. Yellow vegetables and red meat c. Carrots d. Milk 17. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has noted been linked to meningitis in humans? a. S. pneumonia b. H. influenza c. N. meningitis d. Cl. difficile 18.A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is. a. The life span of RBC is 45 days. b. The life span of RBC is 60 days. c. The life span of RBC is 90 days. d. The life span of RBC is 120 days. 19. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? a. Following surgery b. Upon admit c. Within 48 hours of discharge d. Preoperative discussion 20. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in? a. Trust vs. mistrust b. Initiative vs. guilt c. Autonomy vs. shame d. Intimacy vs. isolation 22. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in? a. Trust vs. mistrust b. Initiative vs. guilt c. Autonomy vs. shame d. Intimacy vs. isolation 23. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? a. 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg b. 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg c. 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg d. 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg 24. When you are taking a patient’s history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking? a. Elavil b. Calcitonin c. Pergolide d. Verapamil 25. Which of the following conditions would a nurse not administer erythromycin? a. Campylobacterial infection b. Legionnaire’s disease c. Pneumonia d. Multiple Sclerosis

Nclex Q & A (few questions) Question: 1. Alzheimer's patient incontinent of urine during the night times. The nursing care includes a) Offers bed pan every 2 hours b) Limit fluids during evening times c) Foley's catheter 2. After immediate post operative hysterectomy patient to observe (or) Nursing care includes a) Observe vaginal bleeding b) Urine output c) Vital signs 3. Dilantin prescribed to the patient, instructions to patient include a) Reticulocyte counts b) Platelet counts 4. On the ECG found a straight line, first Nurse a) Assess the patient b) Cardiopulmonary resuscitation c) IV fluids 5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate a) Urine output 30-40ml/hr b) BP c) Vital signs d) Skin turgor 6. 20 week pregnant most concerned a) Butterfly rash on both cheeks and nose b) Uterus palpate at the level of symphysis pubis c) Sereous fluid drain in the breasts d) Breast enlargement 7. The sterile technique is broken when: a) The sterile field and supplies are wet b) Clean the area peripheral to center 8. The metal piece is embedded on the left eye a) Pressure dressing is applied on the left eye b) Dressing is applied on both eyes c) Irrigate the eye with saline 9. After cerebral angiogram, patient is a) Encourage fluids b) obseve contrast medium in the urine c) walking

10. Using clean, non sterile gloves, care is appropriate a) wash the genitelia........YES/NO Answers:The following possible best answers are based on the information found in nursing textbooks, and the underlying principle for safe and effective care that NCLEX is testing for. 1. Alzheimer's patient incontinent of urine during the night times. The nursing care includes a) Offers bed pan every 2 hours-NO, would be appropriate to bring the client to the toilet or commode every 2 hours during the day, but this action means you disturb the client's sleep. b) Limit fluids during evening times, BEST ANSWER-(Source: Black & Hawks, Medical-Surgical Nursing 7th edition) Specific interventions for the Alzheirmer's client with urinary incontinence: "Sometimes the client forgets where the bathroom is located. Having bright lights and frequently taking the client there may help control incontinence. Fluid intake after the dinner meal can be restricted to maintain continence during the night." c) Foley's catheter-NO, would increase risk of lower urinary tract infection, inappropriate and not necessary. 2. After immediate post operative hysterctomy patient to observe (or) Nursing care includes a) Observe vaginal bleeding b) Urine output c) Vital signs-BEST ANSWER, as this provides the best/most information about the client's response to surgery and anesthesia. 3. Dilantin prescribed to the patient, to instruct the patient that includes a) Reticulocyte counts-Yes, this will test for decreased reticulocyte count a sign that the patient is developing aplastic anemia, a potentially life threatening side effect of Dilantin therapy. b) Platelet counts-No, however Dilantin can decrease the platelet count and result in thrombocytopenia. Aplastic anemia is considered to be more serious (Davis Drug Guide) 4. On the ECG found a straight line, first Nurse a) Assess the patient-BEST ANSWER, always assess the patient to be sure there is no equipment malfunction, and/or to confirm the information on the monitor. b) Cardiopulmonary resuscitation c) IV fluids 5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate a) Urine output 30-40ml/hr BEST ANSWER, the patient's fluid balance/hydration status is best evaluated by assessing urine output. Urine output should be between 0.5 and 1.0 mL/kg/hr, which for a 130 lb adult would be between 29.5 -59 mL/hr. Most nursing textbooks consider 30 mL/hr of urine output to indicate appropriate fluid balance/hydration. b) BP c) Vital signs d) Skin turgor For b, c, and d many other factors can affect these findings. Urine output directly correlates with the patient's hydration status/fluid balance. 6. 20 week pregnant most concerned A ) Butterfly rash on both cheeks and nose-NO this is Cholasma the "mask of pregancy", result of hormonal changes in pregnancy. b) Uterus palpate at the level of symphysis pubis-BEST ANSWER this correlates with 12 weeks gestation and the

patient in the question is 20 weeks. This is a significant difference. c) Sereous fluid drain in the breasts-NO, leaking of clear fluid from the breasts during pregnancy is not unusual. d) Breast enlargement-NO, the breast enlarge during pregnancy. 7. The sterile technique is broke when a) The sterile field and supplies are wet-BEST ANSWER, this would allow microorganisms to enter the sterile field through the wet surface. b) Clean the area peripheral to center-NO, this is inappropriate technique but response a, specifically describes how a sterile field can be contaminated and is an important principle in maintaining sterile fields. 8. The metal piece is embedded on the left eye a) Pressure dressing is applied on the left eye-NO, this would "push" the object further into the eye. b) Dressing is applied on both eyes-BEST ANSWER, you want to keep the left eye still, and because both eyes move together the uninjured eye must be covered to prevent movement in the injured eye. c) Irrigate the eye with saline-NO, the object is embedded, meaning deep within the eye. Irrigation will not remove the object but theoretically it could cause it to move resulting in further damage. 9. After cerebral angiogram, patient is a) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are administer the client is hydrated to facilitate excretion of the dye. b) obseve contrast medium in the urine-NO, should not be observable to patient or nurse. c) walking-NO, bedrest would be maintained for a prescribed period of time. 10. Using clean, non sterile gloves care is appropriate a) wash the genitelia........YES/NO- YES, this is not a sterile procedure.

Question: A patient is receiving 1,000 ml of 5% glucose and 0.45% normal saline with 40 mEq of potassium chloride. most important for nurse to monitor the patient : A. pulse rate B. daily weight C. skin turgor Answer1: I would say, always check for urine output before commencing anything with Potassium because it can only be excreted in the urine. Hence if you are dehydrated & have decrease urine output & commenced on K+ hyperkalemia will arise leading to cardiac arrythmia. Answer2: The answer is pulse rate

Question: 1)a young patient most likely to get lead poisining if?

a. he is drinking from a ceramic pitcher. b. father refurnishes old furniture at their home 2) a TB pt understands that he can reduce the risk of spreading his disease if he states? a. i wont sleep in same room w/ my wife for 1-2 months b. i will stay away from pregnant women and children c. i will use plastic utensil when i eat 3) 4 years old with salmonella what u should do? a. private room b. isolation c. place in a room with 4 year old with cellulitis d. keep door closed at all times. 4) wat herb would help with vomiting? a. ginkgo b. ginseng. c. ginger root d. echinacea 5) allergic to sulfa wat not to take? a. ma huang b. echinacea. 6) mother called a nurse from home stating that her child having chicken pox, which of the following statements by the mother needs immediate follow up? a. father of the child with liver failure b. sibling with anemia c. child just had tonsillectomy d. child has intermittent low grade fever 7) client with allergy to sudafed ..which of the statments is correct? a. i will take valerian b. i will take ma huang c. i will take echinacea for acute viral inf. d. i will take black cohosh 8) food processing a. frozen food can be defrost for up to six hours b. frozen food which has been defrost can be return back to fridge. c. cook perishable food should cover and cool d. frozen food should be defrost by hot water 9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and the nurse refused to let him play for wat reason? a. it will get contaminated with bacteria b. it will accumalate moisture c. it could cause a fire 11) a mother reported that her son is throwing up each time she feeds him wat would be the best question u ask? a. did u warm up the formula b. wot kind of formula did u give him c. does ur son feel hungry each time he throws up d. does ur son have a jelly like stool 12) a patient had aids the nurse should advise?

a. cook ur meat very well b. not to eat in the same table with family c. avoid crowds Answer: 1)a young patient most likely to get lead poisining if? a. he is drinking from a ceramic pitcher. b. father refurbishes old furniture at their home > ANSWER is B. probably if he refurbishes an old furniture at home.. that is, if the furniture has old paint on it and during 60's paints have lead content on it (heavy metals) and if you need to remove that, chips from the old paint may be taken by a kid that leads to Pb poisoning 2) a TB pt understands that he can reduce the risk of spreading his disease if he states? a. i wont sleep in same room w/ my wife for 1-2 months b. i will stay away from pregnant women and children c. i will use plastic utensil when i eat ****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of chemotherapy and that (+) PTB will no longer be communicable.. and 1-2 months is long! CHildren are more susceptible to acquire Primary complex and pregnant women are susceptible and almost vulnerable to all type of illnesses.. There is no need for the patient to separate their utensils since PTB is airborne and not by contact in terms of transmission.. so i go for B answer. 3) 4 years old with salmonella what u should do? a. private room b. isolation c. place in a room with 4 year old with cellulitis d. keep door closed at all times. *** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by Enteric.. therefore Enteric precaution is needed and handwashing is very important and gown and gloves, diaper or bedpan in necessary. Option B, and D are all for pulmonary tuberculosis precautions. I suppose, the answer is A. place in a private room. 4) wat herb would help with vomiting? a. ginko b. ginsing. c. ginger root d. echinacea ****> ginger root is good for nausea.. most especially in morning sickness but in moderation for pregnant women... Option C is the answer 5) allergic to sulfa wat not to take? a. ma huang b. echinacea. ...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok.. 6) mother called a nurse from home stating that her child having chicken pox..which of the following statements by the mother needs immediate follow up? a. father of the child with liver failure b. sibling with anemia c. child just had tonsillectomy

d. child has intermittent low grade fever I think the answer is C. the child that just had tonsillectomy. i think the child is immunocompromised. and varicella (Chicken pox) is a viral one.. we all know that tonsils are one of the lymph defenses we have against any infection.. Im not really sure with this answer. 7) client with allergy to sudafed ..which of the statments is correct? a. i will take valerian b. i will take ma huang c. i will take echinacea for acute viral inf. d. i will take black cohosh **valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea is for immune booster but not to be taken with patients with progressive systemic disorders such as AIDS, PTB, HIV, etc. black cohosh is for menopause. *** don't you think that Echinacea is the correct option??

8)food processing a. frozen food can be defrost for up to six hours b. frozen food which has been defrost can be return back to fridge. c. cook perishible food should cover and cool d. frozen food should be defrost by hot water usually, frozen food must be thawed at cool tap water for freshness. not in the microwave because it can be cooked outside and raw inside, not in the hotwater with same principle. so i believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok but it is unsafe since salmonella can start thriving in.. Answer is OPTION A. 9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and the nurse refused to let him play for wot reason? a. it will get contaminated with bacteria b. it will accumalate moisture c. it could cause a fire ** The answer is OPTION C. Usually car toy have friction on it for the wheels to run.. Oxygen supports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire could commence. 11) a mother reported that her son is throwing up each time she feeds him wat would be the best question u ask? a. did u warm up the formula b. wot kind of formula did u give him c. does ur son feel hungry each time he throws up d. does r son have a jelly like stool ***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or currant like stool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in the Ileoceccal area.. 12) a patient had AIDS the nurse should advise? a. cook ur meat very well b. not to eat in the same table with family c. avoid crowds ***>> if you have AIDS, u are immunocompromised.. therefore you are prone to infection.. neutropenic precaution is advised and one that is a must is Avoiding Crowds.. Correct option is C.

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