Comprehensive NCLEX-RN Practice Exam

#5 latest edition 2024(contain rationale)

1. Question

Category: Physiological Adaptation

Mr. Rodriguez is admitted with severe pain in the knees. Which form of arthritis is
characterized by urate deposits and joint pain, usually in the feet and legs, and
occurs primarily in men over age 30?

• A. Septic arthritis

• B. Traumatic arthritis

• C. Intermittent arthritis

• D. Gouty arthritis
Correct Answer: D. Gouty arthritis
Gouty arthritis, a metabolic disease, is characterized by urate deposits and pain in
the joints, especially those in the feet and legs. Urate deposits don’t occur in
septic or traumatic arthritis.
• Option A: Septic arthritis results from bacterial invasion of a joint
and leads to inflammation of the synovial lining.
• Option B: Traumatic arthritis results from blunt trauma to a joint or
ligament.
• Option C: Intermittent arthritis is a rare, benign condition marked by
regular, recurrent joint effusions, especially in the knees.
2. Question

Category: Pharmacological and Parenteral Therapies

A heparin infusion at 1,500 units/hour is ordered for a 64-year-old client with
stroke in evolution. The infusion contains 25,000 units of heparin in 500 ml of
saline solution. How many milliliters per hour should be given?
 • A. 15 ml/hour

• B. 30 ml/hour

• C. 45 ml/hour

• D. 50 ml/hour
Correct Answer: B. 30 ml/hour
An infusion prepared with 25,000 units of heparin in 500 ml of saline solution
yields 50 units of heparin per milliliter of solution. The equation is set up as 50
units times X (the unknown quantity) equals 1,500 units/hour, X equals 30
ml/hour.
• Option A: 15 ml/hr is incorrect based on the computation used.
• Option C: 45 ml/hr is more than the correct milliliters to be infused
based on the computation.
• Option D: 50 ml/hr is incorrect because it is way more than the
correct milliliter to be infused.
3. Question

Category: Physiological Adaptation

A 76-year-old male client had a thromboembolic right stroke; his left arm is
swollen. Which of the following conditions may cause swelling after a stroke?

• A. Elbow contracture secondary to spasticity.

• B. Loss of muscle contraction decreasing venous return.

• C. Deep vein thrombosis (DVT) due to immobility of the ipsilateral side.

• D. Hypoalbuminemia due to protein escaping from an inflamed

glomerulus.
Correct Answer: B. Loss of muscle contraction decreasing venous return
In clients with hemiplegia or hemiparesis, loss of muscle contraction decreases
venous return and may cause swelling of the affected extremity.
• Option A: Contractures or bony calcifications may occur with a
stroke, but don’t appear with swelling.
• Option C: DVT may develop in clients with a stroke but is more likely
to occur in the lower extremities.
 • Option D: A stroke isn’t linked to protein loss. Higher levels of
protein were associated with a lower risk of stroke. According to a
study, for every 20 grams of protein people ate per day, there is a 26
percent lower risk of stroke.
4. Question

Category: Physiological Adaptation

Heberden’s nodes are a common sign of osteoarthritis. Which of the following
statements is correct about this deformity?

• A. It appears only in men.

• B. It appears on the distal interphalangeal joint.

• C. It appears on the proximal interphalangeal joint.

• D. It appears on the dorsolateral aspect of the interphalangeal joint.

Correct Answer: B. It appears on the distal interphalangeal joint.
Heberden’s nodes appear on the distal interphalangeal joint on both men and
women.
• Option A: It appears on both men and women. They are hard bony
lumps in the joints of the fingers.
• Option C: It does not appear on the proximal, rather, on the distal
interphalangeal joint.
• Option D: Bouchard’s node appears on the dorsolateral aspect of
the proximal interphalangeal joint.
5. Question

Category: Physiological Adaptation

Which of the following statements explains the main difference between
rheumatoid arthritis and osteoarthritis?

• A. Osteoarthritis is gender-specific, rheumatoid arthritis isn’t.

• B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic.

• C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized.

• D. Osteoarthritis has dislocations and subluxations, rheumatoid

arthritis doesn’t.
Correct Answer: B. Osteoarthritis is a localized disease; rheumatoid arthritis
is systemic
Osteoarthritis is a localized disease, rheumatoid arthritis is systemic.
• Option A: Osteoarthritis isn’t gender-specific, but rheumatoid
arthritis is.
• Option C: Osteoarthritis is localized while rheumatoid arthritis is
systemic.
• Option D: Clients have dislocations and subluxations in both
disorders.
6. Question

Category: Basic Care and Comfort

Mrs. Cruz uses a cane for assistance in walking. Which of the following
statements is true about a cane or other assistive devices?

• A. A walker is a better choice than a cane.

• B. The cane should be used on the affected side.

• C. The cane should be used on the unaffected side.

• D. A client with osteoarthritis should be encouraged to ambulate

without the cane.
Correct Answer: C. The cane should be used on the unaffected side
A cane should be used on the unaffected side. A client with osteoarthritis should
be encouraged to ambulate with a cane, walker, or other assistive device as
needed; their use takes weight and stress off joints.
• Option A: If a single assisting hand helps to walk, then logically a
cane might be of potential benefit.
• Option B: A cane should be used on the unaffected side of the
client.
• Option D: The use of a cane is important to prevent further injury or
falls.
7. Question

Category: Pharmacological and Parenteral Therapies

A male client with type 1 diabetes is scheduled to receive 30 U of 70/30 insulin.
There is no 70/30 insulin available. As a substitution, the nurse may give the
client:
 • A. 9 U regular insulin and 21 U neutral protamine Hagedorn (NPH).

• B. 21 U regular insulin and 9 U NPH.

• C. 10 U regular insulin and 20 U NPH.

• D. 20 U regular insulin and 10 U NPH.

Correct Answer: A. 9 U regular insulin and 21 U neutral protamine Hagedorn
(NPH).
A 70/30 insulin preparation is 70% NPH and 30% regular insulin. Therefore, a
correct substitution requires mixing 21 U of NPH and 9 U of regular insulin.
• Option B: Using this dosage would be incorrect and may produce
no effect on the client’s blood sugar level.
• Option C: This is an incorrect insulin dose. Incorrect administration
can result in transient and serious hypoglycemia and hyperglycemia,
wide glycemic excursions, and diabetic ketoacidosis.
• Option D: This is an incorrect dosage for the prescribed insulin.
Glycemic control is poorer in those who lacked confidence in their
ability to choose correct doses.
8. Question

Category: Pharmacological and Parenteral Therapies

Nurse Len should expect to administer which medication to a client with gout?

• A. Aspirin

• B. Furosemide (Lasix)

• C. Colchicines

• D. Calcium gluconate (Kalcinate)

Correct Answer: C. Colchicines
A disease characterized by joint inflammation (especially in the great toe), gout is
caused by urate crystal deposits in the joints. The physician prescribes colchicine
to reduce these deposits and thus ease joint inflammation.
• Option A: Although aspirin is used to reduce joint inflammation and
pain in clients with osteoarthritis and rheumatoid arthritis, it isn’t
indicated for gout because it has no effect on urate crystal
formation.
 • Option B: Furosemide, a diuretic, doesn’t relieve gout. It is a loop
diuretic that prevents the body from absorbing too much salt. This
allows the salt to be passed in the urine.
• Option D: Calcium gluconate is used to reverse a negative calcium
balance and relieve muscle cramps, not to treat gout.
9. Question

Category: Physiological Adaptation

Mr. Domingo with a history of hypertension is diagnosed with primary
hyperaldosteronism. This diagnosis indicates that the client’s hypertension is
caused by excessive hormone secretion from which of the following glands?

• A. Adrenal cortex

• B. Pancreas

• C. Adrenal medulla

• D. Parathyroid
Correct Answer: A. Adrenal cortex
Excessive secretion of aldosterone in the adrenal cortex is responsible for the
client’s hypertension. This hormone acts on the renal tubule, where it promotes
reabsorption of sodium and excretion of potassium and hydrogen ions.
• Option B: The pancreas mainly secretes hormones involved in fuel
metabolism.
• Option C: The adrenal medulla secretes the catecholamines —
epinephrine and norepinephrine.
• Option D: The parathyroids secrete parathyroid hormone.

10. Question

Category: Health Promotion and Maintenance

For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet to-
dry dressing change every shift, and blood glucose monitoring before meals and
bedtime. Why are wet-to-dry dressings used for this client?

• A. They contain exudate and provide a moist wound environment.

• B. They protect the wound from mechanical trauma and promote

healing.
 • C. They debride the wound and promote healing by secondary
intention.

• D. They prevent the entrance of microorganisms and minimize wound

discomfort.
Correct Answer: C. They debride the wound and promote healing by secondary
intention
For this client, wet-to-dry dressings are most appropriate because they clean the
foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by
secondary intention.
• Option A: Moist, transparent dressings contain exudate and provide
a moist wound environment.
• Option D: Hydrocolloid dressings prevent the entrance of
microorganisms and minimize wound discomfort.
• Option B: Dry sterile dressings protect the wound from mechanical
trauma and promote healing.
11. Question

Category: Reduction of Risk Potential

Nurse Zeny is caring for a client in an acute Addisonian crisis. Which laboratory
data would the nurse expect to find?

• A. Hyperkalemia

• B. Reduced blood urea nitrogen (BUN)

• C. Hypernatremia

• D. Hyperglycemia
Correct Answer: A. Hyperkalemia
In adrenal insufficiency, the client has hyperkalemia due to reduced aldosterone
secretion.
• Option B: BUN increases as the glomerular filtration rate is reduced.
BUN is handled primarily by glomerular filtration with little or no
renal regulation or adaptation in the course of declining renal
function, they essentially reflect GFR.
• Option C: Hyponatremia is caused by reduced aldosterone
secretion. Aldosterone deficiency causes hyponatremia through two
 mechanisms: the increased levels of ADH and subsequent
upregulation of aquaporin-2 water channels in the renal tubules, and
the extracellular volume depletion-induced reduction in glomerular
filtration rate.
• Option D: Reduced cortisol secretion leads to impaired
gluconeogenesis and a reduction of glycogen in the liver and
muscle, causing hypoglycemia.
12. Question

Category: Physiological Adaptation

A client is admitted for treatment of the syndrome of inappropriate antidiuretic
hormone (SIADH). Which nursing intervention is appropriate?

• A. Infusing I.V. fluids rapidly as ordered.

• B. Encouraging increased oral intake.

• C. Restricting fluids.

• D. Administering glucose-containing I.V. fluids as ordered.

Correct Answer: C. Restricting fluids.
To reduce water retention in a client with SIADH, the nurse should restrict fluids.
• Option A: Rapid infusion of IV fluids would further increase the
client’s overload.
• Option B: The client should be instructed to restrict his fluid intake.
It is also important to restrict sodium intake because higher
correction rates have been associated with osmotic demyelination.
• Option D: Administering fluids by any route would further increase
the client’s already heightened fluid load.
13. Question

Category: Reduction of Risk Potential

A female client tells nurse Nikki that she has been working hard for the last 3
months to control her type 2 diabetes mellitus with diet and exercise. To
determine the effectiveness of the client’s efforts, the nurse should check:

• A. Urine glucose level.

• B. Fasting blood glucose level.

 • C. Serum fructosamine level.

• D. Glycosylated hemoglobin level.

Correct Answer: D. Glycosylated hemoglobin level.
Because some of the glucose in the bloodstream attaches to some of the
hemoglobin and stays attached during the 120-day lifespan of red blood cells,
glycosylated hemoglobin levels provide information about blood glucose levels
during the previous 3 months.
• Option A: Urine glucose levels only show the glucose levels in the
urine at that specific time.
• Option B: Fasting blood glucose only gives information about
glucose levels at the point in time when they were obtained.
• Option C: Serum fructosamine levels provide information about
blood glucose control over the past 2 to 3 weeks.
14. Question

Category: Pharmacological and Parenteral Therapies

Nurse Trinity administered neutral protamine Hagedorn (NPH) insulin to a
diabetic client at 7 a.m. At what time would the nurse expect the client to be
most at risk for a hypoglycemic reaction?

• A. 10:00 am

• B. Noon

• C. 4:00 pm

• D. 10:00 pm
Correct Answer: C. 4:00 pm
NPH is an intermediate-acting insulin that peaks 8 to 12 hours after
administration. Because the nurse administered NPH insulin at 7 a.m., the client is
at greatest risk for hypoglycemia from 3 p.m. to 7 p.m.
• Option A: At 10:00 am, the insulin given would not have reached its
peak.
• Option B: During noontime, risk for hypoglycemia would still be low.
• Option D: 10:00 pm is already a late time for the peak action of
insulin.
15. Question
Category: Physiological Adaptation
The adrenal cortex is responsible for producing which substances?

• A. Glucocorticoids and androgens

• B. Catecholamines and epinephrine

• C. Mineralocorticoids and catecholamines

• D. Norepinephrine and epinephrine

Correct Answer: A. Glucocorticoids and androgens
The adrenal glands have two divisions, the cortex, and medulla. The cortex
produces three types of hormones: glucocorticoids, mineralocorticoids, and
androgens.
• Option B: Epinephrine, which is a catecholamines, is produced in the
medulla. It causes smooth muscle relaxation in the airways or
contraction of the smooth muscle in arterioles, which results in blood
vessel constriction in kidneys, decreasing or inhibiting blood flow to
the nephrons.
• Option C: Catecholamines are produced in the medulla. They help
the body respond to stress or fright and prepare the body for “fight-
or-flight” reactions.
• Option D: The medulla produces catecholamines — epinephrine and
norepinephrine.
16. Question

Category: Physiological Adaptation

On the third day after a partial thyroidectomy, Proserfina exhibits muscle
twitching and hyperirritability of the nervous system. When questioned, the client
reports numbness and tingling of the mouth and fingertips. Suspecting a life-
threatening electrolyte disturbance, the nurse notifies the surgeon immediately.
Which electrolyte disturbance most commonly follows thyroid surgery?

• A. Hypocalcemia

• B. Hyponatremia

• C. Hyperkalemia
 • D. Hypermagnesemia
Correct Answer: A. Hypocalcemia
Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed
accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7
days after surgery. Thyroid surgery doesn’t directly cause serum sodium,
potassium, or magnesium abnormalities.
• Option B: Hyponatremia may occur if the client inadvertently
received too much fluid; however, this can happen to any surgical
client receiving I.V. fluid therapy, not just one recovering from
thyroid surgery.
• Option C: Hyperkalemia is not associated with thyroid surgery. It is
usually found in patients with reduced renal excretion of potassium
and magnesium.
• Option D: Hypermagnesemia usually is associated with reduced
renal excretion of potassium and magnesium, not thyroid surgery.
17. Question

Category: Reduction of Risk Potential

Which laboratory test value is elevated in clients who smoke and can’t be used as
a general indicator of cancer?

• A. Acid phosphatase level

• B. Serum calcitonin level

• C. Alkaline phosphatase level

• D. Carcinoembryonic antigen level

Correct Answer: D. Carcinoembryonic antigen level
In clients who smoke, the level of carcinoembryonic antigen is elevated.
Therefore, it can’t be used as a general indicator of cancer. However, it is helpful
in monitoring cancer treatment because the level usually falls to normal within 1
month if treatment is successful.
• Option A: An elevated acid phosphatase level may indicate prostate
cancer. Prostatic acid phosphatase is a non-specific
phosphomonoesterase synthesized in prostate epithelial cells and its
level proportionally increases with prostate cancer progression.
 • Option C: An elevated alkaline phosphatase level may reflect bone
metastasis. When abnormal bone tissue is being formed by cancer
cells, levels of alkaline phosphatase increase. Therefore, high levels of
this enzyme could suggest that a patient has bone metastasis.
• Option B: An elevated serum calcitonin level usually signals thyroid
cancer. Calcitonin can be measured as a blood test to help diagnose
medullary thyroid cancer and its level can indicate the amount of
medullary thyroid cancer present before thyroid surgery.
18. Question

Category: Physiological Adaptation

Francis with anemia has been admitted to the medical-surgical unit. Which
assessment findings are characteristic of iron-deficiency anemia?

• A. Nights sweats, weight loss, and diarrhea

• B. Dyspnea, tachycardia, and pallor

• C. Nausea, vomiting, and anorexia

• D. Itching, rash, and jaundice

Correct Answer: B. Dyspnea, tachycardia, and pallor
Signs of iron-deficiency anemia include dyspnea, tachycardia, and pallor as well
as fatigue, listlessness, irritability, and headache.
• Option A: Night sweats, weight loss, and diarrhea may signal
acquired immunodeficiency syndrome (AIDS).
• Option C: Nausea, vomiting, and anorexia may be signs of hepatitis
B.
• Option D: Itching, rash, and jaundice may result from an allergic or
hemolytic reaction.
19. Question

Category: Health Promotion and Maintenance

In teaching a female client who is HIV-positive about pregnancy, the nurse would
know more teaching is necessary when the client says:

• A. The baby can get the virus from my placenta.”

• B. “I’m planning on starting on birth control pills.”

 • C. “Not everyone who has the virus gives birth to a baby who has the
virus.”

• D. “I’ll need to have a C-section if I become pregnant and have a baby.”

Correct Answer: D. “I’ll need to have a C-section if I become pregnant and
have a baby.”
A Cesarean section delivery isn’t necessary when the mother is HIV-positive.
• Option A: The human immunodeficiency virus (HIV) is transmitted
from mother to child via the transplacental route.
• Option B: The use of birth control will prevent the conception of a
child who might have HIV.
• Option C: It’s true that a mother whose HIV positive can give birth
to a baby who’s HIV negative.
20. Question

Category: Health Promotion and Maintenance

When preparing Judy with acquired immunodeficiency syndrome (AIDS) for
discharge to the home, the nurse should be sure to include which instruction?

• A. “Put on disposable gloves before bathing.”

• B. “Sterilize all plates and utensils in boiling water.”

• C. “Avoid sharing such articles as toothbrushes and razors.”

• D. “Avoid eating foods from serving dishes shared by other family

members.”
Correct Answer: C. “Avoid sharing such articles as toothbrushes and razors.”
The human immunodeficiency virus (HIV), which causes AIDS, is most
concentrated in the blood. For this reason, the client shouldn’t share personal
articles that may be blood-contaminated, such as toothbrushes and razors, with
other family members.
• Option A: There is no need to use gloves because HIV is not
transmitted by bathing.
• Option B: HIV cannot be transmitted through the utensils used by
an infected person.
• Option D: HIV isn’t transmitted by serving dishes used by a person
with AIDS.
21. Question

Category: Physiological Adaptation

Nurse Marie is caring for a 32-year-old client admitted with pernicious anemia.
Which set of findings should the nurse expect when assessing the client?

• A. Pallor, bradycardia, and reduced pulse pressure

• B. Pallor, tachycardia, and a sore tongue

• C. Sore tongue, dyspnea, and weight gain

• D. Angina, double vision, and anorexia

Correct Answer: B. Pallor, tachycardia, and a sore tongue
Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious
anemia. Other clinical manifestations include anorexia; weight loss; a smooth,
beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue;
and paresthesia of the hands and feet.
• Option A: Tachycardia, instead of bradycardia, and reduced pulse
pressure are present in a client with pernicious anemia. The heart
may start to beat faster to make up for the reduced number of red
blood cells in the body.
• Option C: Weight loss, instead of weight gain, is a common
symptom of pernicious anemia. A B12 deficiency can be
counteracted with a dose of the vitamin, causing energy levels to
regulate and the metabolism to work harder to burn up fuel. The
result is weight loss when the deficiency is mitigated, but adding B12
to a body with sufficient levels doesn’t really increase natural effects.
• Option D: Double vision isn’t a characteristic finding in pernicious
anemia. However, vision loss associated with vitamin B12 deficiency
can occur even in well-nourished individuals who can’t absorb
enough B12 to support healthy vision.
22. Question

Category: Management of Care

After receiving a dose of penicillin, a client develops dyspnea and hypotension.
Nurse Celestina suspects the client is experiencing anaphylactic shock. What
should the nurse do first?
 • A. Page an anesthesiologist immediately and prepare to intubate the
client.

• B. Administer epinephrine, as prescribed, and prepare to intubate the

client if necessary.

• C. Administer the antidote for penicillin, as prescribed, and continue to

monitor the client’s vital signs.

• D. Insert an indwelling urinary catheter and begin to infuse I.V. fluids as

ordered.
Correct Answer: B. Administer epinephrine, as prescribed, and prepare to
intubate the client if necessary.
To reverse anaphylactic shock, the nurse first should administer epinephrine, a
potent bronchodilator as prescribed.
• Option A: The physician is likely to order additional medications,
such as antihistamines and corticosteroids; if these medications don’t
relieve the respiratory compromise associated with anaphylaxis, the
nurse should prepare to intubate the client.
• Option C: No antidote for penicillin exists; however, the nurse
should continue to monitor the client’s vital signs. A client who
remains hypotensive may need fluid resuscitation and fluid intake
and output monitoring; however, administering epinephrine is the
first priority.
• Option D: An indwelling catheter is not needed in a client
experiencing anaphylactic shock; however, IV fluids may be ordered
by the physician after.
23. Question

Category: Reduction of Risk Potential

Mr. Marquez with rheumatoid arthritis is about to begin aspirin therapy to reduce
inflammation. When teaching the client about aspirin, the nurse discusses
adverse reactions to prolonged aspirin therapy. These include:

• A. Weight gain.

• B. Fine motor tremors.

• C. Respiratory acidosis.
 • D. Bilateral hearing loss.
Correct Answer: D. Bilateral hearing loss.
Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing
loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after
the therapy is discontinued.
• Option A: Aspirin does not cause weight gain. Weight only
influenced the relationship between aspirin and long-term risks of
colorectal cancer, with benefits lost at higher body weights.
• Option B: Aspirin doesn’t lead to fine motor tremors. In a study, the
proportion of aspirin users did not differ in essential tremor cases or
controls.
• Option C: Large or toxic salicylate doses may cause respiratory
alkalosis, not respiratory acidosis. Direct stimulation of the cerebral
medulla causes hyperventilation and respiratory alkalosis.
24. Question

Category: Health Promotion and Maintenance

A 23-year-old client is diagnosed with human immunodeficiency virus (HIV). After
recovering from the initial shock of the diagnosis, the client expresses a desire to
learn as much as possible about HIV and acquired immunodeficiency syndrome
(AIDS). When teaching the client about the immune system, the nurse states that
adaptive immunity is provided by which type of white blood cell?

• A. Neutrophil

• B. Basophil

• C. Monocyte

• D. Lymphocyte
Correct Answer: D. Lymphocyte
The lymphocyte provides adaptive immunity — recognition of a foreign antigen
and formation of memory cells against the antigen. Adaptive immunity is
mediated by B and T lymphocytes and can be acquired actively or passively.
• Option A: The neutrophil is crucial to phagocytosis. Phagocytosis is
a process by which certain living cells called phagocytes ingest or
engulf other cells or particles.
 • Option B: The basophil plays an important role in the release of
inflammatory mediators. Basophils play a role in preventing blood
clotting because they contain heparin. This is a naturally occurring
blood-thinning substance.
• Option C: The monocyte functions in phagocytosis and monokine
production. Monocytes are bone marrow-derived leukocytes that
circulate in the blood and spleen.
25. Question

Category: Physiological Adaptation

In an individual with Sjögren’s syndrome, nursing care should focus on:

• A. Moisture replacement.

• B. Electrolyte balance.

• C. Nutritional supplementation.

• D. Arrhythmia management.
Correct Answer: A. Moisture replacement.
Sjogren’s syndrome is an autoimmune disorder leading to progressive loss of
lubrication of the skin, GI tract, ears, nose, and vagina. Moisture replacement is
the mainstay of therapy.
• Option B: Electrolyte balance is not the priority problem in Sjögren’s
syndrome. Electrolyte abnormalities, particularly hypokalemia, must
be considered in patients presenting with generalized weakness.
• Option C: Though malnutrition may occur as a result of Sjogren’s
syndrome effect on the GI tract, it isn’t the predominant problem. An
estimated 90% of people with Sjogren’s syndrome have problems
related to eating, enough to cause malnutrition.
• Option D: Arrhythmias aren’t a problem associated with Sjogren’s
syndrome. However, there is a new study that showed a significantly
increased risk of heart attack in patients with Sjogren’s syndrome,
particularly in the first year following diagnosis.
26. Question

Category: Reduction of Risk Potential

During chemotherapy for lymphocytic leukemia, Mathew develops abdominal
pain, fever, and “horse barn” smelling diarrhea. It would be most important for
the nurse to advise the physician to order:

• A. Enzyme-linked immunosuppressant assay (ELISA) test.

• B. Electrolyte panel and hemogram.

• C. Stool for Clostridium difficile test.

• D. Flat plate X-ray of the abdomen.

Correct Answer: C. Stool for Clostridium difficile test.
Immunosuppressed clients — for example, clients receiving chemotherapy, — are
at risk for infection with C. difficile, which causes “horse barn” smelling diarrhea.
Successful treatment begins with an accurate diagnosis, which includes a stool
test.
• Option A: The ELISA test is diagnostic for human immunodeficiency
virus (HIV) and isn’t indicated in this case.
• Option B: An electrolyte panel and hemogram may be useful in the
overall evaluation of a client but aren’t diagnostic for specific causes
of diarrhea.
• Option D: A flat plate of the abdomen may provide useful
information about bowel function but isn’t indicated in the case of
“horse barn” smelling diarrhea.
27. Question

Category: Reduction of Risk Potential

A male client seeks medical evaluation for fatigue, night sweats, and a 20-lb
weight loss in 6 weeks. To confirm that the client has been infected with the
human immunodeficiency virus (HIV), the nurse expects the physician to order:

• A. E-rosette immunofluorescence

• B. Quantification of T-lymphocytes.

• C. Enzyme-linked immunosorbent assay (ELISA).

• D. Western blot test with ELISA.

Correct Answer: D. Western blot test with ELISA.
HIV infection is detected by analyzing blood for antibodies to HIV, which form
approximately 2 to 12 weeks after exposure to HIV and denote infection. The
Western blot test — electrophoresis of antibody proteins — is more than 98%
accurate in detecting HIV antibodies when used in conjunction with the ELISA. It
isn’t specific when used alone.
• Option A: E-rosette immunofluorescence is used to detect viruses in
general; it doesn’t confirm HIV infection.
• Option B: Quantification of T-lymphocytes is a useful monitoring
test but isn’t diagnostic for HIV.
• Option C: The ELISA test detects HIV antibody particles but may
yield inaccurate results; a positive ELISA result must be confirmed by
the Western blot test.
28. Question

Category: Reduction of Risk Potential

A complete blood count is commonly performed before Joe goes into surgery.
What does this test seek to identify?

• A. Potential hepatic dysfunction indicated by decreased blood urea

nitrogen (BUN) and creatinine levels.

• B. Low levels of urine constituents normally excreted in the urine.

• C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels.

• D. Electrolyte imbalance that could affect the blood’s ability to

coagulate properly.
Correct Answer: C. Abnormally low hematocrit (HCT) and hemoglobin (Hb)
levels.
Low preoperative HCT and Hb levels indicate the client may require a blood
transfusion before surgery. If the HCT and Hb levels decrease during surgery
because of blood loss, the potential need for a transfusion increases.
• Option A: Possible renal failure is indicated by elevated BUN or
creatinine levels.
• Option B: Urine constituents aren’t found in the blood. They are
found in urine specimens.
• Option D: Coagulation is determined by the presence of appropriate
clotting factors, not electrolytes.
29. Question

Category: Reduction of Risk Potential

While monitoring a client for the development of disseminated intravascular
coagulation (DIC), the nurse should take note of what assessment parameters?

• A. Platelet count, prothrombin time, and partial thromboplastin time

• B. Platelet count, blood glucose levels, and white blood cell (WBC)
count

• C. Thrombin time, calcium levels, and potassium levels

• D. Fibrinogen level, WBC, and platelet count

Correct Answer: A. Platelet count, prothrombin time, and partial
thromboplastin time
The diagnosis of DIC is based on the results of laboratory studies of prothrombin
time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen
level as well as client history and other assessment factors.
• Option B: Blood glucose levels are not used to diagnose DIC.
Fasting plasma glucose tests or the A1C test help diagnose diabetes.
• Option C: Calcium and potassium levels are not a part of assessment
for DIC. A calcium blood test measures the amount of calcium in the
blood. Potassium blood test is used to diagnose conditions including
kidney disease, high blood pressure, and heart disease.
• Option D: WBC count isn’t used to confirm a diagnosis of DIC. WBC
count is used to diagnose autoimmune and inflammatory diseases.
30. Question

Category: Basic Care and Comfort

When taking a dietary history from a newly admitted female client, Nurse Len
should remember which of the following foods is a common allergen?

• A. Bread

• B. Carrots
 • C. Orange

• D. Strawberries
Correct Answer: D. Strawberries
Common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish,
and eggs.
• Option A: Bread is not a common allergen. Wheat, a common
ingredient in some breads, may cause wheat allergy in some people.
• Option B: Carrots rarely cause allergies. An allergic reaction to
carrots can be one element of oral allergy syndrome, which is also
known as pollen-food allergy syndrome.
• Option C: Oranges rarely cause allergic reactions. If they do, the
reaction is mild.