NCLEX MASTERS PREP QUIZ 100 QARs Ver 1.

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1. 155 A patient says, "It's snowing outside, but the heat is inside my head". Did you know that Columbas sailed off from Spain..good guy never met me too?The nurse reviews this data and determines that this patient is experiencing a speech pattern commonly seen in anemic episodes called: a) Perseveration b) Circumtanstiality c) Neologisms d) Flight of ideas 2. 156 The parents of a child who has suddenly been hospitalized for acute illness state that they should have taken the child to the pediatrici earlier. Which approach by the nurse is appropriate? a) Focus on the child's needs d recovery b) Explain the cause of the child's illness c) Acknowledge that earlier care might have different outcomes d) Accept their feelings without judgment 3. 157 Mr. Ramon, 59 years of age, and is admitted with a diagnosis of cerebral vascular accident CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Ramon complained of a headache before retiring the night before. In addition to the headache d hypertension, which of the following symptoms would you expect Mr. Ramon to exhibit? a) Labored respiration. b) Dysphagia d hemiplegia. c) Aphasia. d) All of the above. 4. 158 Mr. Rossember, 69 years of age, is found unconscious by his wife at is admitted to ER with a diagnosis of cerebral vascular accident CVA). As you assist you note a previous history of hypertension. His wife has also revealed that he complained of a headache before retiring the night before. Unresponsive patients like she may develop a drying of the cornea, which is usually caused by: a) bulging of the eyeballs. b) absence of reflex and tear formation. c) lack of humidity in the room. d) bulging of the eyeballs 5. 160 Martin, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. As a practical nurse, you would expect Martin to exhibit all of the following symptoms EXCEPT: a) increased thirst. b) fatigue. c) increased appetite with weight gain. d) increased urination with enuresis. 6. 161 Martin, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. Because Martin is so young d because his mother works, it is decided to start him on a) regular insulin. b) regular semilente insulin. c) semilente insulin. d) protamine zinc insulin PZI) 7. 162 Which one of the following statements best describes the effects of immobility in children? a) Immobility prevents the normal progression of lguage d fine motor development b) Immobility in children has physical effects similar to those found in adults c) Children are more susceptible to the effects of immobility th are adults d) Children are likely to have prolonged immobility with subsequent complication

8. 164 A patient with heart failure has been instructed by the RN about proper nutrition. The selection of which lunch indicates the patient has learned about sodium restriction? a) Cheese sdwich with a glass of 2% milk b) Sliced turkey sandwich and caned pineapple c) Cheeseburger d baked potato d) Mushroom pizza and ice cream NCLEX MASTER 100 QUESTIONS PREP EXAM BY www.Nclex-masters.net 9. 165 After a patient has intestinal feeding tube inserted, the most accurate method for verification of placement is a) Abdominal x-ray b) Auscultation with air insertion c) Chest xray d) Aspiration for green gastric contents 10. 166 Which of the following agents should be avoided by patients on methotrexate therapy? a) Folic acid b) Vitamin D c) Vitamin C d) Iron 11. 167 The visiting nurse makes a postpartum home visit to a married female patient. Upon arrival, the nurse observes that the patient has a black eye and numerous bruises on her arms and legs. The next nursing intervention would be to a) Call the police to report indications of domestic violence b) Talk with the couple about the findings c) Leave the home because of the unsafe environment d) Interview the patient to determine the origin of the injuries 12. 168 A patient is admitted with severe injuries from auto accident. The patient's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to: a) Begin the ordered pain therapy b) Initiate continuous blood pressure monitoring c) Administer oxygen therapy d) Institute cardiac monitoring 13. 169 The patient is receiving intravenous piggyback infusion of penicillin. Which patient statement would require the nurse's immediate attention? a) "I have a burning sensation when I urinate." b) "I have soreness d aching in my muscles c) "I am itching all over." d) "I have cramping in my stomach." 14. 101-170 The nurse is caring for a patient who is receiving TPA altipase) For a cerebral vascular accident CVA). Which of these nursing interventions should receive priority? a) Maintain bedrest b) mental status c) Monitor vital signs d) Protect invasive lines or tubes 15. 171 Before administering digoxin Loxin) to a patient, which nursing action is a priority? a) Observe respiratory effort b) Check for bowel sounds c) Take the heart rate d) Measure the blood pressure 16. 172 When reinforcing teaching to a depressed patient about a new prription for nortriptyline Pamelor), the nurse must emphasize a) Symptom relief occurs in a few days b) Alcohol use is to be avoided c) Medication must be stored in the refrigerator d) Episodes of diarrhea c be expected 17. 173 The nurse checks a patient with chronic obstructive pulmonary disease. The patient has oxygen per mask for low PaO2 levels. A nursing priority would be to: a) Evaluate SaO2 levels frequently b) Observe skin color chges c) Check for clubbing fingers d) Monitor activity tolerce

18. 174 The nurse is assisting in the assessment of a patient's home in preparation for discharge. Which focus should be given priority consideration? a) Family's understanding of the patient's needs b) Financial status of the patient d family to buy prescribed drugs c) Location of bathrooms d accessibility by patient d) Proximity to emergency services and telephone number 19. 175 The nurse is caring for a two month old infant with a congenital heart defect. Which of the following is a priority nursing action? a) Provide small feedings every three hours b) Maintain intravenous fluids c) Add strained cereal to the diet d) Change formula to reduced calorie 20. 177 The best action to establish correct placement of a gastric tube is for the nurse to a) aspirate for the color and pH test b) inject air while listening for the gastric gurgle c) results of the xray results of tube placement d) measure the residual volume then reinsert the aspirate 21. 177 The nurse is working in a high risk tepartal clinic. A 40 yearold woman in the first trimester gives a thorough health history. Which of the following collected data should receive priority attention by the nurse? a) Her father d brother are insulin dependent diabetics b) She has taken 800 mcg of folic acid daily for the past year c) Her husbd was treated for tuberculosis as a child d) She reports recent use of over the counter sinus remedies 22. 178 The nurse is checking a woman in early labor. While positioning for a vaginal exam, she complains of dizziness d nausea d appears pale. Her blood pressure has dropped slightly. What is the appropriate initial nursing action a) Call the health care provider b) Encourage deep breathing c) Elevate the foot of the bed d) Turn her to her left side 23. 179 The nurse is caring for a patient several days following a cerebral vascular accident CVA). Coumadin warfarin) has been prescribed. Today's prothrombin level is abnormally elevated. Which item is a priority to check? a) Neurological signs b) Lung sounds c) Hom's sign d) Gum bleeding 24. 180 The nurse is caring for a patient who is receiving procainamide Pronestyl) intravenously. What is a priority for the nurse to do for her patient? a) Hourly urinary output b) Blood pressure c) Continuous ECG readings d) Neurological signs 25. 181 A patient is receiving a nitroglycerin NTG) infusion for unstable gina. What would be a priority for monitoring the effects of this medication? a) Blood pressure b) Cardiac labs c) Rhythm strips d) Respiratory rate 26. 182 The partner of a patient with Alzheimer's disease expresses concern about the burden of care giving. Which action by the nurse should be a priority? a) help caregiver with a support group b) Suggest that friends need to visit regularly c) Schedule a home visit each week d) Develop a telephone support system 27. 183 A nurse is to collect a sputum specimen for acidfast bacillus AFB) from a patient. Which action should the nurse take first? a) Ask patient to cough sputum into container b) Have the patient take several deep breaths c) Provide appropriate specimen container d) Assist with oral hygiene 28. 184 Following chgeof report on orthopedic unit, which patient should the nurse see first:

a) 16 yearold who had open reduction of a fractured wrist ten hours ago b) 20 yearold in skeletal traction for two weeks since a motor cycle accident c) 72 yearold recovering from surgery after a hip replacement two hours ago d) 75 yearold who is in skin traction prior to plned hip pinning surgery. 29. 185 The nurse is caring for a postoperative patient who develops abdominal wound evisceration. The first nursing intervention should be to a) Medicate the patient for pain b) Alert the family of the need to leave the room c) Cover the wound with sterile saline dressing d) Place the bed in a MidFowler's position 30. 186 Postoperative nursing care for inft who has had a pyloromyotomy would include which of these items? a) Bld diet appropriate for age b) Intravenous fluids for three to four days c) NPO then glucose and electrolyte solutions d) Formula or breast milk as tolerated 31. 187 A patient receives high doses of potassium over 30 minutes. Which is a priority to check prior to giving this medication? a) Oral fluid intake b) Bowel sounds c) Grip strength d) Urine output 32. 188 A nurse is to administer meperidine hydrochloride Demerol) 100 mg, atropine sulfate Atropisol) 0.4 mg, d promethizine hydrochloride Phenerg) 50 mg IM to a preoperative patient. Which action should the nurse take first? a) Raise the side rails on the bed b) Place the call bell within reach c) Instruct the patient to remain in bed d) Have the patient empty bladder 33. 190 A patient calls the PN because of onset of chest pain. Which of these statements would require the most immediate action? a) "When I take in a deep breath, it stabs like a knife." b) "The pain came on after dinner. That soup seemed very spicy." c) "When I turn in bed to reach the remote for the TV, my chest hurts." d) "I feel like a balloon is blowing up in my chest." 34. 181b- Ms. Olaery is bedridden. The nurse is evaluating whether the family members understand how to position the patient correctly. Which of the following should the nurse observe? a) The extremities should always be extended to prevent contractures. b) Lower arm d leg are always supported in the lateral positions. c) The spine should have maximal lordosis in almost all positions. d) The family should change the position at least every two hours. 35. 191 A victim of a motor vehicle accident is brought to the emergency room via ambulce in hypovolemic shock. When placing the patient in a modified Trendelenburg position, the nurse should place the patient a) with the legs only elevated above the heart. b) prone, with the head of the bed elevated. c) supine, with the head of the bed lowered. d) supine, tilting the bed so the head is above the heart. 36. 192 Ms. Jord is bedridden d positioned on her right side. There is a pillow beneath her head. Her right arm is extended near her hip. Her left leg is extended d parallel with the right leg. Which of the following is: a) She should be semiprone with the weight on her upper chest. b) Ms. Jord's right arm should be flexed at the shoulder and elbow. c) There should not be a pillow under her head. d) The patient's right leg should be flexed at the hip and knee 37. 193 The nurse uses a wide stce when moving a heavy box of supplies. Which of the following is the best reason the nurse would do this? Because it a) avoids back strain. b) lowers the of gravity. c) increases stability. d) contracts the muscles. 38. 192 Mr. Lowell is brought in after a motor vehicle accident. He has suffered a head injury d possible spinal injury. When moving him from the stretcher to the bed, the nurse should do the following a) sit up d trsfer patient to the bed b) have the patient move segmentally

c) move the patient with a draw sheet. d) log roll the patient. 39. 195 Carlo is a C4 quadriplegic in a nursing home. Which of the following techniques would the nurse use to trsfer him from bed to wheelchair? a) One nurse dgling the patient, then using a trsfer belt. b) Two nurses, one on either side, lifting Mr. T. with a sheet. c) Two nurses using a mechical lifting device Hoya)+. d) Two people, one at Mr. T.'s knees, the other under his arms 40. 196 The nurse is dangling Ms. S. prior to transferring her from the bed to a wheelchair. Which of the following assessments is essential for the nurse to make before moving the patient? a) Taking the patient's pulse d respiration b) Assessing the patient's height d rge of motion. c) Ensuring that the bed is in the highest position. d) Enlisting the help of other nurse or a CNA. 41. 197 A patient has just been admitted for acute asthma exacerbation and placed in a high Fowler's position. The nurse knows this position is best because it a) is required for the aerosol treatments to work b) is the position for the chest Xray. c) facilitates maximal ventilation. d) allows for chest physiotherapy. 42. 198 Ms. L. is to go home with her family. The nurse is evaluating that the family members c correctly move Ms. L. from the bed to a chair. Which of the following should be seen? a) The patient has one foot slightly in front of the other. b) There is no pause while the patient is standing. c) The transfer belt is placed loosely around the waist. d) The family member les forward from the waist 43. 199 Ms. F. suffered a stroke d has rightsided hemiparesis. The nurse is going to trsfer her from bed to wheelchair. Which of the following is the best method? a) Have the patient put her arms around the nurse's neck. b) Put the wheelchair at a 45 gle to the bed. c) Place the wheelchair about a foot away from the bed d) Position the wheelchair closer to the weaker foot. 44. 200 The nurse knows which of the following is the proper technique for medical asepsis selecting: a) Using your hds to turn off the faucet after hdwashing. b) Chging hospital linen weekly. c) Gloving for all patient contact. d) Gowning to care for a oneyearold child with infectious diarrhea. 45. 201 The nurse is conducting a class on aseptic technique d universal precautions. Which of the following statements is correct d should be included in the discussion? a) The term universal precautions is synonymous with disease or categoryspecific isolation precautions. b) Universal precautions are designed to reduce the number of potentially infectious agents. c) Medical asepsis is designed to decrease exposure to bloodborne pathogens. d) Medical asepsis is designed to confine microorgisms to a specific area, limiting the number, growth, d trsmission of microorgisms. 46. 202 The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap? a) Away from the nurse b) Toward the nurse c) To the nurse's left or right. d) It does not matter as long as the nurse only touches the outside edge 47. 203 For which procedure would the nurse use aseptic technique d which would require the nurse to use sterile technique? a) Aseptic technique for urinary catheterization in the hospital d sterile technique for cleing surgical woundsAseptic technique for food preparation d sterile technique for starting IV line b) Aseptic technique for chging the patient's linen d sterile technique for placing a central line. c) Aseptic technique for a spinal tap d sterile technique for surgery 48. 204 Ms. W. has a draining pressure ulcer on her sacrum d is to be discharged to her daughter's care. The nurse has taught Ms. W.'s daughter to perform dressing chges. Which observation by the nurse indicates the daughter's technique is done correctly? The daughter a) places the forceps used to remove the old dressing on the sterile field b) irrigates the wound from the bottom up.

c) uses only sterile gloves to remove the old dressing. d) washes her hands before each gloving and after the procedure is done. 49. 205 Ms. P. is transferred to a skilled nursing facility from the hospital because she is unable to ambulate due to a left femoral fracture. The nurse knows Ms. P.'s greatest risk factor for developing a pressure ulcer is that she: a) has slightly limited mobility d needs assistance to move from bed to chair b) is 5 ft 4 in tall, 130 lb, d eats more th half of most meals. c) is apathetic but oriented to person, place, d time. d) has good skin turgor, no edema, d her capillary refill is less th three seconds. 50. 206 When doing a skin assessment, the nurse notices a 3cm, round area partial thickness skin loss that looks like a blister on the patient's sacrum. The nurse knows this is a a) stage IV pressure ulcer. b) stage II pressure ulcer. c) stage III pressure ulcer. d) stage I pressure ulcer. 51. 207 When plning for the care of a patient with a pressure ulcer on the sacrum, the nurse would include which of the following? a) Having a pressure relieving device such as egg crate mattress or gel flotation pad. b) Positioning the patient with a donut around the area to relieve pressure on the ulcer. c) Massaging the sacrum, concentrating on the bony prominences d reddened areas. d) Using a heat lamp twice a day to dry the wound. 52. 208 The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressings is best? a) Wet gauze dressing. b) Moisturevapor permeable dressing. c) Wet to dry dressing. d) Dry gauze dressing. 53. 209 When evaluating a patient with a pressure ulcer, the nurse understands that the best response to treatment of the sacral pressure ulcer on a patient with a hip fracture would be indicated by a) absence of clinical signs of infection including redness, warmth, swelling, pain, odor, and exudate. b) increased mobility including the ability to reposition self in bed or wheelchair d walking with assistce. c) the patient's nutritional status including adequate protein; carbohydrates; fats; vitamins A, B, C, d K; d minerals including copper, iron, d zinc. d) the patient's skin status including length, width, depth, condition of the wound margins, d stage of the ulcer as well as the integrity of the surrounding skin. 54. 210 A patient with a disorder of the hypothalamus and is on a hypothermia blanket. The nurse should make which of the following assessments? a) Document the patient's ability to sweat. b) Ensure the patient's skin is warm d dry. c) Confirm that the patient is alert d oriented. d) Record baseline vital signs, neurologic status. 55. 211 When Mr. C. is placed on a hypothermia blket, which of the following should be included in the nursing care pl? a) Placing the patient directly on the blanket. b) Taking frequent vital signs, and doing skin assessments. c) Monitoring Mr. C.'s temperature through the hypothermia machine's rectal probe. d) Ensuring the hypothermia blket continues to cool until the patient's temperature reaches 98.6 F. 56. 212 The physician's orders for a patient include warm compresses to the left leg three times a day for treatment of open wound. The nurse should a) place both a dry covering and waterproof material over the compress b) use medical aseptic techniques throughout the procedure. c) wet the compress d apply it directly to the area d) remove the compress after about five minutes. 57. 214 Mr. Shanon is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water a) 105 F 40.5 C). b) 90 F 32 C). c) 110 F 43 C). d) 65 F 18 C). 58. 215 A patient. has sprained his ankle ambulating. The physician would order cold applied to the injured area to: a) reduce the 's temperature. b) relieve pain and bleeding.

c) aid in reabsorbing the edema. d) increase circulation to the area. 59. 216 The nurse is talking with a mother to assess her child. A positive response to which would indicate the child is in the al stage of psychosexual development as descrribed by Freud? a) Does he put everything in his mouth?" b) "Does he say 'No!' to everything you say?" c) "Does he like to dress up d pretend to be his father?" d) "Does he seem jealous when you show affection to his father?" 60. 217 The nurse is beginning to establish a nursepatient relationship with Ms. E. who was referred for help in maging her children. Ms. E. arrives late for appointments d focuses on her busy schedule, the difficulty in parking, d other reasons for being late. The nurse best interprets this behavior as: a) trsference. b) countertrsference. c) identification. d) Resistance 61. 218 Which cognitive skill would the nurse expect a sixyearold child to be in the process of developing? a) Understanding of basic rules. b) Ability to understd abstract concepts. c) Recognition of object permence. d) Recognition of object permence. 62. 219 A nurse is part of a community task force on teenage suicide. The task force is considering all of the following steps in effort to reduce teen suicide. Which action represents primary prevention? a) Encourage emergency room staff to request psychiatric consultation for adolescents who overdose. b) Educate teachers, counselors, d school nurses in recognition d early intervention with suicidal teens. c) Provide community programs, such as Scouts, which increase selfesteem for children d adolescents. d) Increase the number of inpatient adolescent psychiatric beds available in the community. 63. 220 Mrs. Frail has remained close to the nurse all day. When the nurse talked with other patients during dinner, Mrs. F. tried to regain the nurse's attention d then beg to shout "You're just like my mother. You pay attention to everyone but me!" The best interpretation of this behavior : a) The nurse exceeded her care for one patient b) Mrs. Frail has been simply spoiled by her family. c) The nurse has failed to meet the patient's needs. d) Mrs. Frail is demonstrating transference 64. 221 During the focused assessment of a patient with major depression, the nurse may ask which of the following s? a) "You seem to have a lot of energy; when did you last have six or more hours of sleep?" b) "You seem to be gry with your family now; when was it that you last got along?" c) "Have you had y thoughts of harming yourself?"+"You seem to be listening to something. Could you tell me about it?" 65. 222 Which of the following nursing diagnoses would be most appropriate for a patient who is diagnosed as bipolar I disorder, single anemic episode and is intrusive, argumentative, d severely critical of peers? a) Impaired social interaction related to narcissistic behavior as evidenced by inability to sustain relationships. b) Risk for injury related to extreme hyperactivity as evidenced by increased agitation and lack of overt behavior. c) Social isolation related to feelings of inadequacy in social interaction as evidence by problematic interaction with others d) Defensive coping related to social learning patterns as evidenced by difficulty interacting with others. 66. 223 A male strong adult is in acute mic phase of bipolar disorder. He talks d paces incesstly, frequently shouting d threatening other patients. The nurse expects the patient's care pl to include which of the following? a) Monitor blood lithium levels. b) Monitor patient during phototherapy. c) Monitor patient after electroconvulsive therapy. d) Teach patient to avoid foods with tyramine 67. 224 The nurse is preparing to administer lithium Eskalith) to a patient with bipolar disorder. The patient complains of nausea d muscle weakness, d his speech is slurred. His lithium level is 1.6 mEq/L. The best action for the nurse to take is to; a) chart the patient's symptoms after giving the lithium. b) administer an antiparkinsonism drug. c) explain that these are common side effects d withhold the patient's lithium. d) administer antilithium immediately

68. 225 Mr. Capote, a patient with paroid schizophrenia, has a delusion of persecution. He tells the nurse, "They are out to get me. They're spying on me." The nurse's best initial response is : a) I don't want to hurt you; we here to care of you" b) How would they spy on you here?" c) Tell me how they're trying to get you." d) I know they wouldn't wt to hurt you." 69. 226 "The nurse recognizes that the patient with posttraumatic stress disorder PTSD), is improving when he: a) states he feels "numb" most of the time. b) drinks alcohol to cope with his feelings. c) talks about a benefit of the traumatic experience. d) attends weekly group therapy. 70. 227 A woman is found wdering on campus after a fraternity party. She is disheveled d does not know who she is. She has no recollection of the evening. She is diagnosed with dissociative amnesia subsequent to a rape. The most appropriate nursing diagnosis for the nurse to formulate is : a) ineffective individual coping b) personal identity disturbance c) anxiety related to alteration in memory d) high risk for violence, self directed 71. 228 The nurse finds, during the initial assessment of the star player on the basketball team, that he is not concerned about the sudden paralysis of his "shooting arm." This behavior is known as :n a) secondary gain. b) la belle indifference c) malingering. d) hypochondriasis 72. 229 Mike family brought him into the hospital because of his my somatic complaints. He has been seen by my medical specialists past without discovery of organic specifics. a) "The nurse assesses that Mike is experiencing which of the following problems? b) Conversion disorder c) dysmorphic disorder. d) Malingering e) Hypochondriasis 73. 230 Mrs. Wyatt is hospitalized for treatment of a conversion disorder. She complained of paralysis of her right side after her husband left. She seems unconcerned about her paralysis. appropriate long term goal for the nurse to formulate is that Mrs. Waytt. Will: a) cope effectively with stress without recurring to conversion. b) identify stressors within herself behavior c) express feelings about the conflict in her relationship d) develop increased sense of relatedness to others 74. 231 An antibiotic intramuscular) IM injection for a two yearold child is ordered. The total volume of the injection equals 2.0 ml The correct action is to a) administer the medication in 2 separate injections b) give the medication in the dorsal gluteal site c) call to get a smaller volume ordered d) check with pharmacy for a liquid form of the medication 75. 232 A patient has been taking Procardia for Raynaud's disease d hypertension. Which finding would indicate that the patient may be having a side effect of the medication? a) Decreased urinary output b) Facial flushing c) Cyosis of the lips d) Increased pain in fingers 76. 233 The nurse monitors a patient after the treatment of bradycardia with intravenous atropine sulfate. Which of these findings should be reported to the health care provider immediately? a) Frequent palpitations b) Increased salivation c) Bronchial spasms d) Frequent urination 77. 234 The health care provider has written "Morphine sulfate 2 mgs IV every threetofour hours prn for pain" on the chart of elderly patient in extended care facility. The PN has no other licensed persons working that . The initial action by the PN should be to a) Check with the pharmacist b) Hold the medication d contact the health care provider c) Administer the prescribed dose as ordered

d) Give half of the dose at a time 78. 235 The nurse would reinforce the need to take alendronate Fosamax) as prescribed by the physician : a) On empty stomach d water only b) After meals to increase absorption levels c) With added calcium and milk d) With milk two hours after meals 79. 236 The nurse is reinforcing teaching about the use of nonsteroidal tiinflammatory NSAIDs) drugs to a group of arthritic patients. To minimize the side effects, the nurse should emphasize a) Lying down for 30 minutes after taking the medication b) Using alcohol in moderation unless driving c) Taking the drug with food, milk, or tacids d) Taking the medication one hour before or two hours after meals 80. 237 A patient with chronic obstructive pulmonary disease ( COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which finding by the nurse would require immediate intervention? a) Decreased blood pressure d respirations b) Flushing d headache c) Restlessness d palpitations d) Increased heart rate d blood pressure 81. 238 A patient with an anemic disorder has a new prescription for Xanax ( alpazolam). When reinforcing teaching to the patient about the drug's actions and side effects, which item should the nurse emphasize? a) Shortterm relief can be expected b) The medication acts as a stimult c) Dosage will be increased as tolerated d) Initial side effects often continue 82. 239 A patient with heart failure has a prription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication a) Sometimes alters consciousness b) May lead to oliguria c) C predispose to dysrhythmias d) May cause irritability d xiety 83. 240 Dorreen adolescent female is newly diagnosed with bulimia. The nurse is reinforcing instructions to the patient d her parents about the theraputic benefits of Tofril. Which statement demonstrates understanding by the patient? a) "I will begin to feel better after a few days." b) "I only need to take this medication until feel better" c) "I will need to take the medication for two weeks before see it benefit." d) "I c double the medication if I miss a dose." 84. 241 A patient is admitted for (Lithium Lithe) toxicity. Which finding should the nurse report immediately to the health care provider? a) Peripheral edema b) Vomiting with diarrhea c) Dizziness with unsteady gait d) Onset of anemic mood 85. 242 A patient is recovering from a hip replacement d is taking Tylenol #3 every 3 hours for pain. In checking the patient, which finding suggests a side effect of the analgesic? a) Bruising at the operative site b) Elevated heart rate c) Decreased platelet count d) No bowel movement for 3 days 86. 243 A nurse observes a family member administer a rectal suppository by having the patient lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the patient was told by the family member to turn to the right side d the patient did this. What is the appropriate comment for the nurse to make? a) "Why don't we now have the patient turn back to the left side." b) "That was done correctly. Did you have y problems with the insertion?" c) "Let's check to see if the suppository is in far enough." d) "Did you feel y stool in the intestinal tract? 87. 244 Which of these points should be reinforced during the discharge instructions to a patient who is prescribed warfarin sodium Coumadin) for the next six months? a) Eliminate all dark green lettuce from your diet b) Report y changes in the color of your stools d urine

c) Take limited aspirin or nonsteriodal tiinflammatories for minor pains d) Use a soft tooth brush with expectation that a little bleeding of your gums might occur after brushing your teet 88. 245 Pediatric Nursing brbrThe nurse is testing reflexes in a fourmonthold inft as part of the neurologic asse,ssment. Which of the following findings would indicate abnormal reflex pattern d area of concern in a fourmonthold inft? a) Closes hand tightly when palm is touched b) Begins strong sucking movements when mouth area is stimulated c) Hyperextends toes in response to stroking sole of foot upward d) Does not extend d abduct extremities in response to loud noise 89. 246 The mother of a three month old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants? a) Infant cereal can be introduced by spoon when the extrusion reflex fades b) Solid foods should be given as soon as the infant's first tooth erupts c) Pureed food c be offered when the infant has tripled his birth weight d) Infant formula or breast milk provides adequate nutrients for the first time 90. 247 The nurse is assessing a six month old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is area of concern indicating a need for further evaluation? a) Absence of Moro reflex b) Closed posterior fontel c) Three pound weight gain in two months d) Moderate head lag when pulled to sitting position 91. 248 The nurse is giving anticipatory guidance regarding safety d injury prevention to the parents of 18 month old toddler. Which of the following actions by the parents indicates sp understding of the safety needs of a toddler? a) Supervise the child in outdoor, fenced play areas b) Teach the child swimming d water safety c) Use automobile booster seat with lap bell d) Allow child to cross the street with four yea old sibling 92. 250 The parent of a three yearold child brings the child to the clinic for a well child checkup. Which of these assessment findings made by the nurse is area of concern d requires further investigation? a) Child is unable to ride a tricycle b) Hasn't developed the ability to hop on one foot c) Only uses gestures to indicate wants. d) Weight gain of four pounds in last year. 93. 251 adult woman is seen in the clinic for treatment of a minor burn. While assessing the woman the nurse obtains data suggesting that the patient has developed hyperthyroidism. Which data are most suggestive of hyperthyroidism? a) "Nervousness, frequent crying, weight loss, and tachycardia. b) Intolerce to cold, cool clammy skin, d bradycardia. c) Weight gain, puffiness around eyes, d extreme fatigue d) Dry skin, constipation, d memory defects 94. 252 Randy, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that Randy must used salucytes? a) Chorea b) swollen, painful, hot joints that c) Polyarthritis d) Erythema marginatum 95. 253 The nurse is caring for a patient with advanced cancer of the breast. She complains of hypoguesia. The nurse should recommend a) eating dry crackers. b) monitoring intake d output c) using spices to enhance food flavors d) weighing her before d after meals 96. 254 An adult is admitted to the hospital to undergo a stapedectomy for the treatment of otosclerosis. Which findings elicited during physical assessment are most indicative of otosclerosis? a) Bone conduction is greater th air conduction b) Bone conduction is equal to air conduction c) Air conduction is greater th bone conduction d) Sound lateralizes to the unaffected ear.

97. 255 Four year old Amy has been blind since birth. 109%"She has been attending a nursery program for the visually impaired. To continue independence in her activities of daily living, when her lunch tray arrives, the nurse will : a) offer to feed her in a good gesture b) pl that foods on her tray are set up like a clock c) put food on her fork and hand her the fork d) tell her 2 trays are in front of her, one at the top, one at the bottom. 98. 256 Bumping into a crib, the nurse notices that the newborn inft demonstrates the Moro startle) reflex. This is seen as the following: a) alternate flexion, adduction, d extension of the legs b) extension of one side of the while the other side is flexed c) abduction, extension, d adduction of arms to embracing position d) flexion of the knees d hips with movement of the legs upward 99. 257 The nurse realizes that the discharge instructions given to a woman with placenta previa are understood when the nurse overhears the patient tell her husband a) "We c't have sex for a few days" b) "I have to return in a few days for a vaginal exam." c) "I will have to have a ceasarea for this d other pregnancies." d) "I c go back to part time work beginning tomorrow." 100. 258 Miss Rodriguez is 88yearold patient at a longterm care facility. Prior to administering y medication or treatment to this patient the nurse must confirm identity by ? asking the patient if she is Miss Rodriguez: a) asking the patient if she is Miss Rodriguez b) reading the patient's identification bracelet c) reading the patient's medical record d) asking the roommate to state the patient's name 101. 259 A young adult is involuntarily admitted to the psychiatric unit in a anemic state. Upon arrival on the unit he is unable to sit, d it is very difficult to follow what he is saying because of the rate d content of speech. He is very provocative d refuses to eat or drink. The area of disturbance that poses the greatest physical dger to this patient is n a) physical activity b) perceptual input c) sensory input d) social activity 102. 263 The nurse in the delivery room is caring for the newborn. Which action is the most important d most immediate action for the nurse to take? a) Do the Apgar score within 1 hour for birth defect b) Dry the baby completely and cuddled the baby c) Place identification bracelets on the infantt d the mother d) Prevent infection by doing eye care 103. 264 The nurse is caring for a 30 week baby girl who is currently receiving 15 ml of breast milk via oral gastric tube every three hours. As part of the routine assessment the nurse should assess which of the following? a) Assess for heme in the stool at each bowel movement b) Assess abdominal girth once every three days c) Assess for residual once per d) Assess for tube placement once every 24 hours