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• The nurse is caring for a client with chronic renal failure.

The laboratory results indicate hypocalcemia and
hyperphosphatemia. When assessing the client, the nurse
should be alert for which of the following? Choose all
that apply.
a. Trousseau’s sign
b. Cardiac arrhythmias
c. Constipation
d. Decreased clotting time
e. Drowsiness and lethargy
f. Fractures

• Rationale (a, b, f):

• Hypocalcemia is a calcium deficit that causes

nerve fiber irritability and repetitive muscle
spasms. S/s of hypocalcaemia include
Trousseau’s sign, cardiac arrhythmias,
diarrhea, increased clotting times, anxiety, and
irritability. The calcium-phosphorous
imbalance leads to brittle bones and
pathologic fractures.
• Reference: Williams & Wilkins, , NCLEX-RN, 250- New Format Questions, Lippincott

Publishers, PA-2004, PP-73

Congestive heart failure . Systemic emboli c. Presence of a heart murmur b. The complication that the nurse will constantly observe for is: a.A client has been admitted to the hospital with a diagnosis of suspected bacterial endocarditis.• . Fever d.

kidneys. Heart murmurs fever and night sweats may be present. Sandra Smith’s Review for NCLEX-RN. Those arising in the right heart chambers will terminate in the lungs and left chamber emboli may travel any where in the arteries. • Reference : Smith Sandra. lungs and in the extremities. .• Rationale (b): Emboli are the major problem. brain. New Jersey – 2001 PP-196. Prentice Hall Publishers. Congestive heart failure may be a result. but do not indicate a complication of emboli. 10th edition. but this is not as dangerous an outcome as emboli may occur in the spleen.

The nurse would recognize a deep partial thickness burn because.• Burns are classified according to the depth of tissue destruction. Extends to the dermis and is very painful c. Extends to subcutaneous tissue and is rarely painful d. Involves the epidermis only b. the burn: a. Extends to muscle and bone and is rarely painful .

• Reference: Langerquist Sally. Davis’s NCLEX-RN Success. They have a pink red appearance and are characterized by moisture or blisters.A. F. PA-2001 .PP-639 .• Rationale (b): Deep partial thickness burns involve both the epidermis and some dermis. Davis Publishers.

Raise the casted leg to the level of the heart.• An adult client sustained a fractured tibia three hours ago. and notify the physician d. Administer the ordered narcotic IV. . The pain is more intense with passive flexion of the toes. Which initial action should the nurse take? a. Prepare for emergency fasciotomy b. notify the physician. Now the client is complaining of increasing pain. Raise the casted leg above the heart. The nurse suspects the client is developing compartment syndrome. A long leg cast was applied. and prepare to split the cast. then reassess the client’s pain in 15 minutes c. apply ice.

PP-578. If this does not work to decrease the pressure. a fasciotomy may be necessary. raise the affected extremity only to the level of the heart and remove any constrictive dressing or cast. • Reference: Miller Judith. NSNA NCLEX-RN Review.• Rationale (d): To decrease the pressure within the compartment. USA-2000. 4th edition. Delmar Publishers. .

The nurse is discussing his postoperative instructions with him prior to his discharge from the surgery center. “I need to sleep with this metal eye shield at night. “I should avoid coughing. or if I start seeing double or light flashes” . “I should call the doctor for any bad pain in my eyes that the pain medication doesn’t help. but I can wear my glasses during the day” b. sneezing. Which statement by the client indicates a need for further instruction before he is discharged? • a.• An adult has had a cataract extraction with a lens implant performed on an outpatient basis. “It’s okay to bend over to pick something up from the floor as long as I put the eye shield on” d. and vomiting” c.

. 4th edition. Delmar Publishers. PP-578. NSNA NCLEX-RN Review. USA-2000.• Rationale (c): Bending over should be avoided as it increases intra ocular pressure • Reference: Miller Judith.

and touch down one step with left leg” . “Lift both crutches. then lift and advance crutches. the nurse must teach crutch-walking skills. “Hold both crutches under one arm. Which is the correct technique? a. advance crutches upstairs. then swing through and touch down with the left leg” c. Before the client is discharged. Hold onto rail.• An adult client has a fractured right ankle. “Advance left leg. and swing right leg” d. which was casted in the emergency room. lift body. “Advance crutches and the right leg. advance a short distance and swing through with both legs” b.

• . PP-578. 4th edition. Delmar Publishers. The body weight is supported by the hands on the crutches and on the unaffected extremity (3point). NSNA NCLEX-RN Review. • Reference: Miller Judith. USA-2000.• Rationale (b): The 3-point gait is used when one leg cannot bear weight.

Bronchial breath sounds d. Blood tinged frothy sputum c. Which clinical manifestation would first alert the nurse that the client is experiencing adult respiratory distress syndrome (ARDS)? a.• A client was admitted to the hospital 24 hours ago following pulmonary trauma. An increase in respiratory rate b. Diffuse pulmonary infiltrates on the chest x-ray .

B.• Rationale (a): ARDS usually develops within 24- 48 hours after an initiating event. W. bronchial breath sounds. 2nd edition. Breath sounds are clear in early stages of ARDS. Blood tinged frothy sputum. In most cases. USA-2002PP-151. tachypnea and dyspnea are the first clinical manifestations. and x-ray findings are manifestations which develop after the initiation of pulmonary edema. Saunder’s Publishers. Saunders Q & A Review for NCLEX-RN. • Reference: Silvestri Linda. .

Drainage at the pin site c. Warm toes with brisk capillary refill d. Weak pedal pulses b. Complaints of discomfort .• A nurse is caring for a client with Buck’s traction. Which assessment finding indicates a complication associated with this type of traction? a.

• Reference: Silvestri Linda.B. W. 2nd edition. Saunders Q & A Review for NCLEX-RN. Saunder’s Publishers. USA2002PP-151 .• Rationale (a): Weak pedal pulses are a sign of vascular compromise. which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure this traction.

• The nurse is caring for a client who is scheduled for an MRI study. “I had a total hip replacement five years ago” c. Which statement made by the client warrants further assessment by the nurse? a. “I have been taking a blood thinner and bleed easily” d. “I am allergic to iodine and seafood” b. “My doctor told me never to take laxatives” .

pins etc) may render the client unsuitable for the MRI. PP-580. NSNA NCLEX-RN Review. screws.• Rationale (b): Implanted medical devices (pacemaker. 4th edition. Delmar Publishers. USA-2000. . • Reference: Miller Judith.

Has ever had trouble with uncontrolled bleeding b. Received teaching regarding a low fat diet d. While preparing the client for X-rays.• An adult client is scheduled for gall bladder X- rays in the morning for suspected cholelithiasis. Understands the procedure for local anesthesia . Has any known allergies c. it is most important for the nurse to ask the client if he: a.

4th edition. The client must be assessed for history of allergy to iodine.• Rationale (b): Iodine contrast media is used for gall bladder X-rays. • Reference: Miller Judith. PP-580. USA-2000. NSNA NCLEX-RN Review. . Delmar Publishers.

Lippincott Publishers. NCLEX-RN. • Reference: Williams & Wilkins. Which of the following signs and symptoms of meningeal irritation is the nurse likely to observe? Choose all that apply. • • • • • • • • • Generalized seizures Nuchal rigidity Positive Brudzinski’s sign Positive Kernig’s sign Babinski reflex Photophobia Rationale (b. Babinski reflex is a reflex action of the toes that reflects cortico spinal tract disease in adults. c. . positive Brudzinki. 250. f): Signs of meningeal irritation include nuchal rigidity. PP-61 • . Kernig’s sign and photophobia. May accompany meningitis but is caused by irritation of the cerebral cortex. PA-2004. Other signs are exaggerated and symmetrical deep tendon reflexes as well as opisthotonous generalized seizures.New Format Questions.• The nurse is assessing a 2-year-old client diagnosed with bacterial meningitis. d.

The nurse differentiates between a glucose tolerance test (GTT) and glycosylated hemoglobin assay (Hgb AIC) by explaining that the (Hgb AIC). NSNA NCLEX-RN Review. PP-580. USA-2000. providing an average level over the 2-3 months preceding the test. Delmar Publishers. 2 and 3 hour intervals Reflects blood glucose level over a 2-3 month period Rationale (d): The (Hgb AIC) assay provides information about long-term control of diabetes mellitus.• A client referred to the out patient clinic to have a Glucose Tolerance Test (GTT) and glycosylated hemoglobin assay (Hgb AIC) to assess for questionable diabetes mellitus. • • • • • • • Is used to diagnose diabetes mellitus Involves administration of an oral glucose load Measures serum glucose at 30 minute. 1. The client requests clarification from the clinic nurse regarding these tests. The assay reflects glucose level within erythrocytes. . 4th edition. • Reference: Miller Judith.

Which of the following physiological responses indicates that the digoxin is having the desired effect? • • Increased heart rate • Decreased cardiac output • Increased urine output • Decreased myocardial contraction force • • Rationale (c): Urine output increases due to increased cardiac output and myocardial contraction force. Delmar Publishers. • Reference: Miller Judith.25mg for treatment of her congestive heart failure. 4th edition. PP-581. USA-2000. .• An elderly woman received digoxin 0. NSNA NCLEX-RN Review. increasing perfusion of the kidney. Increase in urine output helps to decrease edema.

Assess gag reflex prior to administration of fluids c. Assess frequently for pain and medicate according to orders d. Maintain nasogastric tube to intermittent suction b.• A nurse is planning care for a client who is having a gastroscopy performed. Included in the plan of care for the immediate post gastroscopy period will be: a. Measures abdominal girth every four hours .

• Rationale (b): Because a local anesthetic

is used to numb the pharyngeal area for
gastroscopy, the nurse must be certain that
the client is able to swallow before giving
food or fluids.
• Reference: Miller Judith, NSNA NCLEX-RN Review, 4th edition,

Delmar Publishers, USA-2000, PP-581.

• The physician has ordered a Schilling’s test for a

client with possible pernicious anemia.
Implementation of the test will require the nurse
a. Administer a mild laxative
b. Initiate a 24-hour-urine collection

c. Administer an intra muscular dose of iron
d. Insert an intravenous catheter

• Rationale (b): A Schilling’s test measures

the percent of Vitamin B12 excreted in a 24
hour urine sample following an intra
muscular loading dose of Vitamin B12 and a
radioactive oral dose of Vitamin B12.
• Reference: Miller Judith, NSNA NCLEX-RN Review, 4th edition,

Delmar Publishers, USA-2000, PP-582.

Maintain bed rest with client in supine position at all time c. Provide tracheostomy care every shift and suction PRN to maintain a patent airway . Ask client questions every hour or two to assess for hoarseness d. Carry out range of motion exercise to the neck and shoulders every shift b.• An adult client is one-day post subtotal thyroidectomy. The nurse planning care for the day knows that it is most important to: a.

persistent hoarseness may indicate laryngeal nerve damage • Reference: Miller Judith. Hoarseness immediately following surgery is related to intubation. . USA-2000. NSNA NCLEX-RN Review. Delmar Publishers. 4th edition. PP-582.• Rationale (c): Damage to the recurrent laryngeal nerve is a major complication of thyroid surgery. But.

Check the ventilator tubing . What is the most appropriate initial response by the nurse? a. The high-pressure alarm (PAP) begins to sound repeatedly. The client is sleeping quietly. Call the respiratory therapist to check the ventilator b. Turn the client to stimulate coughing c.• A client in the ICU is on a volume cycled mechanical ventilator. Obtain arterial blood for blood gas analysis d.

USA-2000. has decreased airway compliance. .• Rationale (d): Unless the client is coughing. The tubing should be checked first. or has an airway obstruction. Delmar Publishers.PP-583. NSNA NCLEX-RN Review. • Reference: Miller Judith. 4th edition. a high pressure alarm usually indicates water collection in or kinking of ventilator tubing.

Wheezing heard only during exhalation d.The absence of wheezing during inhalation c.Noticeably diminished breath sounds .• A nurse is performing a respiratory assessment on a client with asthma.Loud wheezing heard throughout the lung fields b. The nurse is alert to a worsening of the client‟s respiratory status when which of the following occurs? a.

Saunder‟s Q & A Review for NCLEX- RN. USA-2002 PP-160 . 2nd edition. while others with severe attack may have no audible wheeze because of the decreased airflow. W.B. wheeze is heard both on inspiration and expiration. Clients with minor attacks may experience loud wheezes. Wheezing is heard first on exhalation but as the attack progresses.• Rationale (d): Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Saunder‟s Publishers. • Reference: Silvestri Linda.

then remove the air from the IV line c. and the client is dyspneic.Hang another IV bag as soon as possible. What is the best initial nursing action? • a.• An adult client has a central line placed for IV fluids.Begin CPR and call the code team • . the IV line is full of air. When the nurse enters the room the IV bottle is empty.Clamp the tubing and place the client on the left side with head down d.Notify the physician and administer oxygen via nasal canula immediately b.

• Reference: Miller Judith. and cyanosis. chest pain. NSNA NCLEX-RN Review. USA-2000. 4th edition. hypotension. PP-583 . Delmar Publishers. Then call physician and administer oxygen.• Rationale (c): Air embolism occurs frequently with central lines with sudden onset of dyspnea. The best initial nursing action is to clamp the IV line and turn the client to the left side to trap the air in the right side of the heart so it does not enter the pulmonary artery.

• A nurse performs a finger stick glucose test on a client receiving total parenteral nutrition (TPN).Administer insulin d. What nursing action is most appropriate at this time? a.Notify the physician .Decrease the flow rate of the TPN c.Stop the TPN b. Results show the client‟s glucose level to be greater than 400mg/dL.

2nd edition. USA-2002. Saunder‟s Q & A Review for NCLEX- RN. Saunder‟s Publishers.• Rationale (d): Hypoglycemia is a complication of TPN.B. W. • Reference: Silvestri Linda. The nurse reports abnormalities to the physician. . PP-158.

Dependent edema .Coolness and pallor of the extremity b. The nurse would assess for which of the following signs and symptoms indicative of infection? a.Diminished distal pulse d.Presence of a “hot spot” on the cast c.• The nurse is assessing the casted extremity of a client.

• Reference: Silvestri Linda. or the presence of „hot spots‟ which are areas that are warmer than others. Saunder‟s Publishers.• Rationale (b): Signs and symptoms of infection under a casted extremity include odor or purulent drainage from the cast. W. Saunder‟s Q & A Review for NCLEX- RN.B. USA-2002 PP-1 . 2nd edition.

Patch the right eye and let the client resume activity after 24 hours c.• An adult client presents with the sudden onset of the appearance of “floating black spots” in her right eye.Plan for emergency surgery as the client is in danger of losing her eyesight d. What should the nurse expect to do in the care of this client? • a. There is no pain but the client is very frightened. The client sees a black shadow in her peripheral vision.Place patches on both eyes and plan for strict bed rest b.Administer a cholinergic eye drop (pilocarpine) to decrease intraocular pressure • • .

USA-2000. 4th edition. NSNA NCLEX-RN Review. . • Reference: Miller Judith. which requires patching of both eyes to minimize eye movement and bed rest with a flat or slightly raised head of the bed to prevent separation of the retina and choroid layers.• Rationale (a): The client is displaying signs of a detached retina. PP-580. Delmar Publishers.

Clear speech .31. a.A nurse is caring for a client with an intracranial aneurysm who was previously alert.. c. Ptosis of the left eyelid. • . b. Which finding would be an early indication that the level of consciousness (LOC) is deteriorating? • a. Frequent spontaneous speech. Drowsiness. d.

Early changes in LOC relate to alertness and verbal responsiveness.• Answer: C • Rationale: Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III and does not relate to LOC . • Reference: Linda Silvestri.Comprehensive review for the NCLEX-PN examination.P 863. slight slurring of speech and mild drowsiness are early signs of decreasing LOC . .P. Less frequent speech. 3rd edition.

The client asks for a snack and something to drink.Hot herbal tea with graham crackers b.Cocoa with honey and toast .Vanilla wafers and milk d. The nurse determines that the most appropriate choice for this client to meet nutritional needs is: a.Iced coffee with peanut butter and crackers c.• A nurse is caring for a client with trigeminal neuralgia (tic douloreux).

the client needs to eat or drink lukewarm. nutritious food that is soft and easy to chew.B. 2nd edition. W. • Reference: Silvestri Linda. USA-2002 PP-166 . Saunder‟s Publishers. Saunder‟s Q & A Review for NCLEX- RN.• Rationale (c): Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain.

Monitor the BP to assess for fluid volume overload c. Which of the following is a priority nursing intervention? • a.Label the dressing with the date and time of catheter insertion d.Prepare the client for a chest x-ray examination • .• A nurse has just finished assisting a physician in placing a central intravenous (IV) line.Obtain a temperature to monitor for infection b.

Saunder‟s Publishers. W. USA-2002 PP-167. • Reference : Silvestri Linda. 2nd edition.• Rationale (d): A major risk associated with CVP line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. .B. Chest X-ray is taken to determine the catheter tip placement before initiating IV therapy. Saunder‟s Q & A Review for NCLEX- RN.

• A nurse has just administered a purified protein derivative (PDD) skin test to a client.The presence of a wheal.A large area of erythema c. The nurse determines that the test is positive if which of the following occurs? • a.An induration of 10mm or greater b.Client complaints of constant itching . d.

B. Saunder‟s Publishers. Saunder‟s Q & A Review for NCLEX- RN. . USA-2002 PP-171. W.• Rationale (a): An induration of 10mm or greater is usually considered a positive result. Erythema is not a positive reaction. 2nd edition. • Reference: Silvestri Linda.

• A client with diabetes mellitus has a blood glucose level of 644mg/dL.Metabolic alkalosis • . The nurse interprets that this client is most at risk of developing which type of acid base imbalance? • a.Respiratory alkalosis c.Metabolic acidosis d.Respiratory acidosis b.

. Saunder‟s Publishers. Saunder‟s Q & A Review for NCLEXRN. When the body does not have sufficient circulating insulin. • Reference: Silvestri Linda. 2nd edition. USA-2002 PP-173.B. The body. the blood glucose level rises. breaks down glycogen or fat for fuel and the by products are acidotic. W.• Rationale (c): DM can lead to metabolic acidosis.

Compensated respiratory alkalosis • . PCO2 of 31mmHg.Uncompensated respiratory acidosis d. and HCO3 of 21mEq/L.Compensated metabolic acidosis c.42.Uncompensated metabolic alkalosis b.• A nurse is reviewing the client‟s most recent blood gas results and the results indicate a pH of 7. The nurse interprets these results as indicative of which acid base imbalance? • a.

35 to 7.45. 2nd edition.45. an opposite effect will be seen between pH and the Pco2. compensation has occurred. Saunder‟s Publishers. the pH and bicarbonate move in the same direction. In a respiratory condition. • Reference: Silvestri Linda. The normal Pco2 is 35- 45mmHg and normal Hco3 is 22-27mEq/L. . In a metabolic condition. USA-2002 PP-193. Saunder‟s Q & A Review for NCLEX-RN.35 – 7. Since the pH is within the normal range of 7.• Rationale (d): The normal pH is 7.B. W.

Glucose c.White blood cells d.Protein b. A nurse assesses for which of the following values that should be negative if the CSF is normal? • a.• An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis.Red blood cells • .

• Rationale (d) : An adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0-5 cells). . Protein (15-45mg/dL) and glucose (45-80mg/dL) are normally present in CSF.

Eating 6 small meals per day b. To minimize complications from eating.Avoiding concentrated sweets c. the nurse would tell the client to avoid doing which of the following? • a.Drinking liquids with meals • .Lying down after eating d.• A client is resuming a diet after hemigastrectomy.

2nd edition.B. Saunder‟s Publishers. USA-2002 PP-178. • Reference: Silvestri Linda. The client should avoid drinking liquids with meals to prevent this. . Saunder‟s Q & A Review for NCLEXRN.• Rationale (d): The client who has had a hemigastrectomy is at risk for dumping syndrome. W.

Left side lying with a small pillow or towel under the puncture site b.Left side lying with the right arm elevated above the head d.Right side lying with a small pillow or towel under the puncture site c.• A nurse has assisted the physician with a liver biopsy that was done at the bedside.Right side lying with the left arm elevated above the head • . the nurse assists the client into which of the following position? • a. On completion of the procedure.

W. USA-2002 PP-186. Saunder‟s Q & A Review for NCLEXRN. This position compresses the liver against the chest wall at the biopsy site.B. the client is assisted to assume a right side lying position with a small pillow or folded towel under the puncture site for 2 hours. • Reference: Silvestri Linda.• Rationale (b): Following a liver biopsy. • . Saunder‟s Publishers. 2nd edition.

When the procedure is complete. the nurse assists the client into which of the following positions initially to maximize the effect of the tube? • • Right side • Left side • Prone • Supine • .• A physician has just inserted a Cantor tube in a client with a bowel obstruction.

Following insertion. . to facilitate movement of the tube. the client is positioned for 2 hours on the right side. Saunder’s Q & A Review for NCLEX-RN. W. 2nd edition. mercury weighted tube. 2 hours on the back with the head elevated.• Rationale (a): The Cantor tube is a single lumen. and then 2 hours on the left. The weight of the mercury carries the tube by gravity. • Reference: Silvestri Linda.B. Saunder’s Publishers. USA-2002 PP-187.

• Which nursing action is the first priority during a generalized tonic-clonic seizure episode? • a.Monitor vital signs.Maintain a patient airway by turning the head to the side c. with special attention directed to respiratory status • . during and after the seizure b.Observe and record all events that occur before.Protect the patient from injury d.

Davis Publishers. PP-639. the patient usually stops breathing for up to a minute. as spontaneous breathing will return.A. . During the initial tonic phase. • Reference: Langerquist Sally. Davis‟s NCLEX-RN Success.• Rationale (c): The first priority is to protect the patient from injury. F. PA-2001. but there is no cause for alarm.

Four-point gait d.• A doctor has ordered ambulation on crutches with no weight bearing on the affected limb.Three-point gait c.Two-point gait b.Tripod gait • • . An appropriate crutch gait for the nurse to teach the patient would be: • a.

• Reference: Langerquist Sally.• Rationale (b): The three point gait is appropriate when weight bearing is not allowed on the affected limb. . Davis Publishers.A. F. PA-2001 PP-639. Davis‟s NCLEX-RN Success.

The nurse assesses the client for: • a.• A client has developed atrial fibrillation with a ventricular rate of 150 beats/min.Nausea and vomiting c.Flat neck veins • • .Hypertension and headache d.Hypotension and dizziness b.

• Rationale (a): The client with uncontrolled AF with a ventricular rate

over 100b pm is at risk for low cardiac output as a result of loss of
atrial kick. The nurse should assess for palpitations, chest pain,
hypotension, pulse deficit, fatigue, weakness, dizziness, syncope,
shortness of breath and distended neck veins.
• Reference: Silvestri Linda, Saunder‟s Q & A Review for NCLEXRN, 2nd edition, W.B. Saunder‟s Publishers, USA-2002 PP-159.

• Nursing preparation for an upper GI series includes:

a.NPO for 24 hours before the procedure
b.Administering an enema or cathartic to enhance visualization
c.Discouraging the patient from smoking the morning of the

procedure because smoking can stimulate gastric motility
d.Instructing the patient that the test involves insertion of a rubber
gastroscopy tube

• Rationale (c): Patients are kept NPO for 6-8 hours and are

encouraged not to smoke or take medications the morning of an upper
GI series.
• Reference : Langerquist Sally, Davis‟s NCLEX-RN Success, F.A.
Davis Publishers, PA-2001 PP-639.

• Urinary output is closely assessed after nephrectomy.Increased specific gravity of urine b.Periorbital edema • • . Which assessment finding is an early indicator of fluid retention in the post-operative period? • a.A urinary output of 50ml/hr d.Daily weight gain of 2 pounds or more c.

F. . Davis‟s NCLEX-RN Success. PA-2001 PP-639. • Reference: Langerquist Sally.A.• Rationale (d): Daily weights are taken following nephrectomy. Increased specific gravity indicates dehydration. Periorbital edema is a later sign. Daily increases of 21b or more are indicative of fluid retention and should be reported to the physician. Davis Publishers.

The patient‟s left leg is shorter than the right leg and internally rotated c.The patient‟s left leg is longer than the right leg and externally rotated b. When comparing the legs. the nurse would most likely make which of the following observations? • a. X-rays reveal a displaced sub capital fracture of the left hip and osteoarthritis.The patient‟s left leg is shorter than the right leg and adducted d.The patient‟s left leg is longer than the right leg and is abducted • .• A 70-year-old woman is brought to the emergency room for treatment after being found on the floor by her daughter.

NY-2003.• Rationale (c): Extremity shortens due to contraction of muscles attached above and below fracture site. PP-185 . • Reference: Irwin Barbara. fragments overlap by 1-2 inches. Extremity usually shortens and externally rotates. 2003-2004 edition. Simon & Schuster Publishers. Kaplan NCLEX-RN.

the nurse knows that the treatment of choice to reduce hyperkalemia is: • a.Morphine sulfate b.• In planning care for a patient with hyperkalemia.Synthetic aldosterone • .Sodium polystyrene sulfonate (Kayexalate) c.Insulin and 50% glucose solution d.

Administration of Kayexalate would not be indicated unless more conservative means were unsuccessful.A. PA-2001. PP-640.• Rationale (c): Potassium is transported back into the cells along with glucose. Davis Publishers. • Reference: Langerquist Sally. Therefore. . the administration of insulin and glucose will facilitate the movement of potassium back into the cell. Davis‟s NCLEX-RN Success. F.

Into the conjunctival sac d.Directly on the dilated pupil • • • .On the inner canthus of the eye c. the nurse should gently pull down the lower lid of the eye and instill the drops: • a.Directly on the central surface of the cornea b.• To correctly instill pilocarpine in a patient‟s eyes.

A. Davis Publishers. • Reference: Langerquist Sally. PP-641. F. .• Rationale (c): Eye drops should be instilled into the conjunctival sac to prevent medication from hitting the sensitive cornea. Davis‟s NCLEX-RN Success. PA-2001.

Constricted pupil and therefore widened outflow channels and increased flow of aqueous fluid c.Constriction of aqueous veins and therefore decreased venous pooling in the eye • . and therefore increased pupil size b.Blocked action of cholinesterase at the cholinergic nerve endings.• Pilocarpine is the drug of choice in the treatment of open angle glaucoma. The expected outcome following administration would be: • a.Impaired vision from decreased aqueous humor production d.

• Rationale (b): Pilocarpine constricts the pupil by causing contraction of the ciliary muscles. Davis Publishers. PA-2001. Davis‟s NCLEX-RN Success. • Reference: Langerquist Sally. thus widening the outflow channels and increasing aqueous flow. . F. PP-641.A.

Standard only on the fourth post operative day b.After 2 days of alternate clamping and unclamping of the tube • .• The nurse tells a postoperative gastrectomy patient that the nasogastric tube will be removed: • a.Thirty six hours after the cessation of bloody drainage d.When bowel sounds are established and the patient has passed flatus or stool c.

. F. • Reference: Langerquist Sally.A. PA-2001 PP-641. Davis‟s NCLEX-RN Success. Davis Publishers.• Rationale (b): The NG tube is removed after bowel sounds have been re established and the patient has passed flatus or stool.

Decreased aldosterone secretion.Hyper bilirubinemia secondary to red blood cell destruction • .• The nurse can expect hyperkalemia to develop following burn damage because there is: • a. and retention of potassium d.Disruption of cell membrane integrity.Increased exudate formation at the burn site b. allowing intra cellular electrolytes to diffuse into the vascular compartment c. increasing sodium excretion.

F. resulting in movement of potassium from intra cellular space to the extra cellular space.• Rationale (b) : Hyperkalemia occurs in burns due to three separate mechanism. • Reference: Langerquist Sally. PA-2001 PP-642 . cellular injury. Davis Publishers. and more hydrogen ions are excreted than potassium ions.A. Davis‟s NCLEX-RN Success. decreased GFR and decreased urine output preventing excretion of increased serum potassium and inadequate tissue metabolism resulting in increased H+ion formation.

as necessary b.Provide several small. well balanced meals c.Keep the environment warm e. Weigh the client daily • • • • .Instill isotonic eye drops. • a.• The nurse is planning care for a client with hyperthyroidism. Which of the following nursing interventions are appropriate? Choose all that apply.Provide rest periods d.Encourage frequent visitors and conversation f.

which can be satisfied by frequent. c.New Format Questions.• Rationale (a. Lippincott Publishers. well-balanced meals. the conjunctivae should be moistened with isotonic eye drops. Heat intolerance and excitability may result the nurse should provide a cool and quiet environment. • Reference: Williams & Wilkins. PA-2004. f): If the client has exophthalmos. 250. The client should be weighed daily to check for weight loss. The nurse should provide the client with rest periods to reduce metabolic demands. small. . . Hyperthyroidism results in increased appetite. NCLEX-RN. a possible consequence of hyper thyroidism. not a warm and busy one. to promote client comfort. PP-3. b.

Ensure a separate IV access for the antibiotic b.Flush the central line with 60ml of normal saline solution before hanging the antibiotic • .Check with the pharmacy to be sure the antibiotic can be hung through the TPN line d. Which action by the nurse is appropriate before hanging the antibiotic solution? • a.• A client receiving total parenteral nutrition (TPN) via a central intravenous (IV) line is scheduled to receive an antibiotic by the IV route.Turn off the TPN for 30 minutes before administering the antibiotic c.

Any other intravenous medication must be administered through a separate .• Answer: a • Rationale: The TPN line is used only for the administration of TPN solution.

Which is the client‟s response least likely to include? • a.Seasonal changes • • . the nurse questions the client about what precipitates an attack.Climate changes b.Exposure to high pollen and mould counts d.Exposure to animal dander c.• While assessing the patient with a history of allergic asthma.

Delmar publishers.USA 2000 PP-613. • Reference: Miller Judith. air pollution are most often associated with non allergic asthma.4th edition. .• Rationale (a): Exacerhation triggered by climate changes (cold air. NSNA NCLEX RN REVIEW.

Relief of ptosis but not of weakness in other facial muscles c. If the patient responds positively to the drug.• Diagnosis of myasthenia gravis is frequently based on the patient‟s response to an intravenous injection of edrophonium (Tensilon).Exacerbation of symptomatology b.A slight increase in muscle strength that is countered by an increase in muscle fatigability • • . the nurse should expect: • a.A prompt and dramatic increase in muscle strength d.

. A positive Tensilon test result. PA-2001 PP-642. F. Davis Publishers. is consistent with the diagnosis of myasthenia gravis.A. is a prompt and dramatic increase in muscle strength. • Reference: Langerquist Sally. Davis‟s NCLEX-RN Success.• Rationale (c): Edrophonium (Tensilon) is a short acting anti cholinesterase compound.

Feelings of hunger b.Constipation c.Increased strength d.• Which would the nurse expect to see with the dumping syndrome? • a.Diaphoresis • .

F. .A. Davis‟s NCLEX-RN Success. • Reference: Langerquist Sally.• Rationale (d): Profuse perspiration is one of the groups of symptoms that happen 5-30 minutes after a high carbohydrate meal or when liquid is taken with meal. Davis Publishers. PA-2001 PP-645.

Hypoglycemia due to increased insulin production b.Dependent edema and severe hypokalemia due to abnormal aldosterone secretion d. the nurse caring for the patient with Cushing‟s syndrome should expect: • a.• Because cortisol is a glucocorticoid. Secretion of ACTH • .Discoloration or hyper pigmentation of the skin due to increased pituitary.Skeletal muscle wasting because glucocorticoids promote protein and fat mobilization c.

Davis Publishers. and the patient‟s extremities may appear wasted • Reference: Langerquist Sally.A. PA-2001 PP-645. F. Davis‟s NCLEX-RN Success. Catabolism from gluconeogenesis occasionally results in a marked decrease in skeletal muscle mass.• Rationale (b): Lassitude and muscle weakness are early clinical signs of Cushing‟s syndrome. .

which increases bone formation • .Lack of weight bearing. which decreases osteoblastic activity b.• The nurse anticipates that osteoporosis may result from prolonged immobilization because of: • a.Lack of weight bearing.Deposition of excess calcium phosphate salts d.Decreased dietary intake c.

Davis‟s NCLEX-RN Success.• Rationale (a): Osteoblastic activity requires the stress and strain of weight bearing to be proportional to osteoclastic activity. When the patient is immobilized. PA-2001 PP-646. • Reference: Langerquist Sally. bone break down takes place. Davis Publishers. F.A. .

The extrinsic factor is produced in the stomach b.Decreased hydrochloric acid production inhibits vitamin B12 re absorption • .• Following gastrectomy surgery the nurse must observe signs of pernicious anemia.The extrinsic factor is absorbed in the antral portions of the stomach c. which may be a problem after gastrectomy because: • a.The intrinsic factor is produced in the stomach d.

A. PA-2001 PP-646. Davis‟s NCLEX-RN Success. . Davis Publishers. F. • Reference: Langerquist Sally.• Rationale (c): Pernicious anemia may occur following subtotal gastrectomy due to the loss of tissue that produces the intrinsic factor.

• A patient has hypotension.Managing pericardial effusion or tamponade • .Improving left ventricular function c. and muffed heart sounds on auscultation. The nurse would anticipate that the patient‟s treatment will be directed at: • a. jugular venous distention.Reducing the degree of ventricular hypertrophy d.Reversing cardiogenic shock b.

. • Reference: Langerquist Sally. Pericardial effusion or cardiac tamponade impairs the vent rides from adequately filling during diastole. F. Davis Publishers. Davis‟s NCLEX-RN Success. PA-2001 PP-647.A.• Rationale (d): The patient‟s signs are consistent with an increase in venous pressure.

Temperature over 1020F b.• Which nursing assessment would identify the earliest indication of increasing intracranial pressure? • a.Widening pulse pressure d.Change in level of consciousness c.Unequal pupils • .

F. PA-2001 PP-647. . Davis‟s NCLEX-RN Success.• Rationale (b): As cerebral hypoxia develops. patient becomes restless and drowsy before any characteristic signs and symptoms. Davis Publishers.A. • Reference: Langerquist Sally. All the other three options are late signs.

• Pg 25 post test 1 .