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Spring 2010 Set 3

(Answers follow all questions)

Fundamentals of Nursing

1. An older adult asks the nurse why a daily bath is necessary. The nurse should
that daily bathing:

A. Stimulates circulation, provides relaxation, and mobilizes joints

B. Adds hydration and prevents dry skin
C. Including combing and brushing of the hair helps to remove excess oil from
the scalp
D. Is necessary to comply with agency policy


2. Which of the following fetal heart rate patterns would the nurse anticipate s
eeing from
a fetus who has anencephaly?

A. Early onset decelerations

B. Absent long-term variability
C. Accelerations
D. Late onset decelerations


3. When caring for a child with a ventricular septal defect (VSD), the nurse sho
monitor for which clinical manifestations of hemodynamic alterations?

Select all that apply:

A. Pulmonic murmur
B. Bradycardia
C. Tachypnea
D. Fatigue
E. Dyspnea
F. Anxiety
Neurological Disorders (Adult)

4. Which of the following actions is a priority for the nurse to perform first i
n a client
with a spinal cord injury who complains of a headache?

A. Administer a beta adrenergic blocker

B. Take the blood pressure
C. Assess the papillary reaction
D. Insert a Foley catheter

Musculoskeletal/Integumentary Disorders (Adult)

5. Which of the following dietary guidelines should the nurse provide to a clien
t with a

A. Three large, high-calorie meals

B. High-fiber foods and 2000 to 3000 ml of fluids daily
C. Low-protein and low-fat foods
D. Limit milk and milk products to two servings daily

Oncological/Immune Disorders (Adult)

6. When planning care for a client being treated for cervical cancer, it would b
e a priority
for the nurse to include which of the following in the plan of care?

A. Instruction on birth control methods

B. Vigorous fluid hydration
C. Assessment of sexual function
D. Daily weights

Cardiovascular Disorders (Adult)

7. Which of the following should the nurse include in the plan of care for the c
experiencing pain from a deep vein thrombosis (DVT) of the leg who is receiving
and warfarin (Coumadin)?

Administration of :
A. Aspirin 325 mg p.o. every 4 hours
B. Patient-controlled analgesic of IV morphine
C. Meperidine (Demerol) 50 mg IM every 3 hours
D. Ibuprofen (Motrin) 400 mg p.o. every 6 hours p.r.n.
Respiratory Disorders (Adult)

8. The nurse is admitting a client who complains of fever, chills, chest pain, a
nd dyspnea.
The client has a heart rate of 110, respiratory rate of 28, and a nonproductive
cough. A chest x-ray confirms a diagnosis of left lower lobe pneumonia. Upon
auscultation of the left lower lobe, the nurse documents which of the following

A. Bronchial
B. Bronchovesicular
C. Vesicular
D. Absent breath sounds

Endocrine Disorders (Adult)

9. The registered nurse is preparing to delegate the nursing tasks for the day.
Which of
the following nursing tasks should the nurse delegate to a licensed practical nu

A. Administer intravenous insulin to a client in diabetic ketoacidosis

B. Administer an oral calcium supplement one hour after meals
C. Develop a medication schedule for a client with diabetes mellitus and
congestive heart failure
D. Assess a client taking iodine for signs of iodine poisoning

GI/GU Disorders (Adult)

10. The nurse is caring for a client in acute renal failure. Which of the follow
ing would
indicate to the nurse that the client is uremic?

A. BUN of 32 mg/dl
B. Serum calcium of 10.5 mg/dl
C. Serum potassium of 2.8 mg/dl
D. Urine specific gravity of 1.030
Sensory Disorders (Adult)

11. In planning pre-op care for a client with a retinal detachment, the nurse sh
include which of the following in the plan of care?

A. Restrict ambulation
B. Maintain flat bed rest
C. Place a patch over the affected eye
D. Have client wear dark glasses for reading and television

Psychiatric and Mental Health (Adult)

12. The nurse is asked to teach a class to a group of clients in a drug rehabili
tation clinic
on the medical complications of cocaine abuse. Which of the following complicati
should the nurse include in the class?

A. Hypotension
B. Cardiac arrhythmias
C. Constipation
D. Kidney failure

1. A: Daily bathing may damage fragile skin in the older adult. Daily combing an
d brushing of
the hair helps stimulate the scalp and distribute the oil. Reasons for daily bat
hing include
stimulating circulations, providing relaxation, and mobilizing joints.

2. B: Absent long-term variability seen on the fetal heart monitor is seen in co

ngenital brain
anomalies such as anencephaly. Anencephaly is a fatal condition in which the inf
ant is born with
a severely underdeveloped brain and skull. The infant most certainly dies shortl
y after birth.

3. C, D, E: Ventricular septal defect is an abnormal connection between the righ

t and left
ventricles. Tachypnea, dyspnea, and fatigue are clinical manifestations that may
worsening hemodynamics and possible congestive heart failure. Pulmonic murmur, b
and anxiety are not manifestations of hemodynamic changes in ventricular septal

4. B: The priority action in a client who has sustained a spinal cord injury and
is complaining of
a severe headache is to take the blood pressure. A severe headache and a systoli
c blood pressure
of 300 mm Hg are suggestive of autonomic dysreflexia or hyperreflexia, which are
threatening if left untreated.

5. B: Although three well-balanced meals are encouraged following a fracture, an

calorie intake is to be avoided because of the limited mobility that predisposes
the client to
weight gain. A high-fiber diet and increased fluid intake are necessary to preve
nt constipation.
Adequate protein and calcium intake must be maintained to ensure adequate healin

6. C: Surgery and radiation therapy for cervical cancer often results in shorte
ning of the vagina,
vaginal dryness, and loss of libido due to emotional issues related to sexuality
and femininity.
Therefore, the client s feelings about sexuality and the partner s feelings should b
e assessed. If a
client is not sexually active, instructions should be given in the use of a vagi
nal dilator and
lubricant to prevent adhesion of the vaginal walls. While instruction about birt
h control methods
may be needed for some clients, treatment for cervical cancer may include total
hysterectomy, so that this would not be appropriate for all clients. Encouraging
fluids and daily
weights are not priorities in cervical cancer care.

7. B: A daily dose of aspirin would be ordered for antiplatelet effect, not for
pain control. A
client with a deep vein thrombosis would be receiving heparin therapy, so intram
injections should be avoided (due to possible hematoma formation at injection si
tes). Ibuprofen
(Motrin) is also contraindicated for a client receiving oral anticoagulants due
to possible drug
interaction. The best solution to this client s pain would be patient-controlled I
V analgesic.
8. A: In the presence of pneumonia there will be bronchial breath sounds over th
e area of
consolidation. The client may also have crackles in the affected side as a resul
t of fluid in the
interstitium and alveoli. Absence of breath sounds is not a usual finding and wo
uld not likely
occur unless there was a serious complication.

9. B: A licensed practical nurse may administer a calcium supplement one hour af

ter meals.
Developing a medication schedule, administering intravenous insulin, and assessi
ng a client
taking iodine for signs of iodine poisoning are tasks that should be performed b
y a registered

10. A: An elevated BUN, or increased nitrogenous wastes in the blood, is classic

uremia in a
client in acute renal failure. A normal BUN is 10 to 20 mg/dl. A serum calcium o
f 10.5 mg/dl
and a urine specific gravity of 1.030 are at the upper range for normal calcium
(9 to 10.5 mg/dl)
and specific gravity (1.010 to 1.030). A serum potassium of 2.8 mg/dl is low (3.
5 to 5.5 mEq/L)
and is not indicative of acute renal failure.

11. C: Placing an eye patch over the affected eye reduces eye movement. Occasion
ally bilateral
patching may be needed. The size and the location of the retinal break may limit
other activities,
such as bending, coughing, and the Valsalva maneuver, to prevent further detachm
ent and to
promote drainage of fluid. Elevating the head of the bed prevents intraocular pr

12. B: Cocaine is a stimulant that works directly on the central nervous system
and produces
cardiac arrhythmias. Cardiac arrhythmias can lead to death for a client who abus
es cocaine.
Hypertension is a complication that occurs with toxic levels of cocaine. Constip
ation does not
occur as a result of cocaine. It is actually diarrhea that occurs. Kidney failur
e is also not a
complication of cocaine use.

Gauwitz, D. (2007). Complete Review for the NCLEX-RN Examination. Clifton, NY: T
homson Delmar Learning.