Comprehensive Review of the Nclex by Saunders 3rd Ed.

7/22/2019 Comprehensive Review of the Nclex by Saunders 3rd Ed.

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COMPREHENSIVE REVIEW OF THE NCLEXRN

EXAMINATION

QUESTIONS AND ANSWERS with RATIONALE

1. The nurse is assessing the child with a suspecteddiagnosis of appendicitis. In assessing the intensity

and progression of the pain, the nurse palpates the

child at McBurneys point. In performing this

assessment, the nurse knows that McBurneys point

is located midway between the

1. Right anterior inferior iliac crest and the

umbilicus.

2. Left anterior superior iliac crest and the

umbilicus.

3. Right anterior superior iliac crest and the

umbilicus.4. Left anterior superior iliac crest and the

umbilicus.

2. The nurse is caring for a client with a burn injury

to the lower legs. Nitrofurazone (furacin) is

prescribed to be applied to the sites of injury. The

nurse documents which of the following in the plan

of care as the appropriate method to apply this

medication?

1. Apply saline soaked dressings over themedication.

2. Apply 1-inch film directly to the burn sites.

3. Apply 116-inch film directly to the burn sites.

4. Apply 1/2-inch film directly to the burn sites

after cleansing the wounds.

3. A client suspected of having an abdominal tumor

is scheduled for a computerized tomography scan

with dye injection. The nurse tells the client that

1. The test may be painful.

2. The dye injected may cause a warm flushing

sensation.

3. Fluids will be restricted following the test.

4. The test takes about 2 hours.

4. The nurse is caring for a client whose magnesiumlevel is 3.5 mg/dL. Which assessment sign/symptom

would the nurse most likely expect to note in the

client based on this magnesium level?

1. Tetany

2.Twitches

3. Positive trousseaus sign

4. Loss of deep tendon reflex

5. The nurse is caring for a client with a diagnosis of

hyperthyroidism. Laboratory studies are performed,and the serum calcium level is 12 mg/dL. Which

medication would the nurse anticipate to be

prescribed for the client?

1.Calcium gluconate

2.Calcium chloride

3.Calcitonin (Calcimar)

4.Large doses of vitamin D

6. The nurse prepares to administer sodium

polystyrene sulfonate (Kayexalate) to the client.Before administering the medication, the nurse

reviews the action of the medication and

understands that it releases

1. Bicarbonate in exchange primarily for sodium

ions.

2. Sodium ions in exchange primarily for

bicarbonate ions.

3. Sodium ions in exchange primarily for

potassium ions.

4. Potassium ions in exchange primarily for

sodium ions.

7. Which of the following clients is least likely at risk

for the development of third spacing?

1. The client with cirrhosis

2. The client with diabetes mellitus.

3. The clent with liver failure


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4. The client with renal failure

8. The nurse is preparing to care for a client

following a gastroscopy procedure. The nurse

includes which most appropriate component in thenursing care plan?

1. Place the client in supine position to provide

comfort.

2. Monitor the clients vital signs every hour for 4

hours.

3. Provide saline gargles immediately on return to

the unit to aid in comfort.

4. Check the gag reflex by using a tongue

depressor to stroke the back of clients throat.

9. Intravenous Ringers lactate solution is prescribed

for the postoperative client. The nursing instructor

asks the nursing student who is caring for the client

about the tonicity of the prescribed intravenous

solution. The nursing student responds correctly by

stating that this solution is

1.Isotonic.

2.Normotonic.

3.Hypotonic.

4.Hypertonic.

10. The nurse reviews the arterial blood gas results

of a client with Guillain-Barre syndrome. The pH is

7.35 and the PCO2 is 50mmHg. The nurse interprets

that this client is experiencing which acid-base

imbalance?

1. Respiratory acidosis

2. Respiratory alkalosis

3. Metabolic acidosis

4. Metabolic alkalosis

11. The client is admitted 24 hours following an

aspirin overdose. The nurse assesses this client for

which signs and symptoms indicating the acid-base

disturbance that can occur in the client?

1.Bradycardia and Hyperactivity

2.Restlessness, confusion and a positive

trousseaus sign

3.Headache, nausea, vomiting and diarrhea

4.Bradypnea, dizziness and paresthesias

12. The adult client with hepatic encephalopathy has

a serum ammonia level of 95 mcg/dL and receives

treatment with lactulose (Chronulac). The nurse

would evaluate that the client had the best and most

realistic response, if the serum ammonia level

changed to which of the following after medication

administration?

1. 80mcg/dL

2. 60mcg/dL

3.10mcg/dL

4.5mcg/Dl

13. The client who suffered a crush injury to the leg

has a highly positive urine myoglobin level. The

nurse assesses this particular client carefully for

signs of

1. Cerebrovascular accident

2. Acute tubular necrosis

3. Respiratory failure

4. Myocardial infarction

14. The adult male client admitted to the hospital

with shock has received fluid volume replacement .

The nurse evaluates that the client has had adequate

fluid resuscitation if the clients repeat hematocrit

level has decreased to which of the following values

in the normal range?

1. 56%

2.48%

3.39%

4.34%

15. The nurse is formulating a plan of care for a

client receiving enteral feedings. Which nursing

diagnosis is of highest priority for this client?

1.Imbalanced Nutrition, Less Than Body

Requirements.


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2. Risk for aspiration

3. Risk for Deficient Fluid Volume

4. Diarrhea

16. A Client who has gastrostomy tube for feedingrefuses to participate in the plan of care, will not

make eye contact, and does not speak to the family

or visitors. The nurse assesses that this client is using

which type of coping mechanism?

1.Self-control

2.Problem-solving

3.Accepting responsibility

4.Distancing

17. The nurse conducting a weight loss programprepares to monitor a clients weight loss. What

method would assess the effectiveness of weight

loss most accurately?

1.Daily weights

2.Serum protein levels

3.Calorie counts

4.Daily intake and output

18. The clinic nurse is monitoring a client with

anorexia nervosa. Which statement if made by aclient would indicate to the nurse that treatment has

been effective?

1.I no longer have a weight problem.

2.I dont want to starve myself anymore.

3.Ill eat until I dont feel hungry.

4.My friends and I went out to lunch today.

19. The nurse is teaching the postgastrectomy client

about measures to prevent dumping syndrome.

Which statement by the client indicates a need forfurther teaching?

1.I need to lie down after eating.

2.I need to drink liquids with meals.

3.I need to eat small meals six times daily.

4.I need to avoid concentrated sweets.

20. A client has been diagnosed with pernicious

anemia. In planning care for the client, the nurse

anticipates that the client will be treated with

1. Thiamine

2. Iron

3. Vitamin B124. Folic acid

21. An older postoperative client has been tolerating

a full liquid diet, and the nurse plans to advance the

diet to solid food as prescribed. Which assessment is

most important for the nurse to make before

advancing the diet to solids?

1.Food preferences

2.Cultural preferences

3. Preference of bowel sounds4.Ability to chew

22. The client with diabetes mellitus has been

instructed in the dietary exchange system. The client

ask the nurse if bacon is allowed in the diet. Which

nursing response is most appropriate?

1. Bacon is much too high in fat.

2. Bacon is not allowed.

3. One strip of bacon may be eaten if you

eliminate one teaspoon of butter.4. Bacon may be eaten if you eliminate one

meat item from your diet.

23. The client with heart disease is provided

instructions regarding a low-fat diet. The nurse

determines that the client understands the diet if

the client states that the food item to avoid is

1.Apples.

2.Oranges.

3.Avocado.4.Cherries.

24. A client with liver cancer who is receiving

chemotherapy tells the nurse that some foods on

the meal tray taste bitter. The nurse would try to


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limit which food that is most l ikely to cause this taste

for the client?

1. Beef

2. Potatoes

3. Custard

4. Cantaloupe

25. A nursing student is caring for a client who has

been admitted to the hospital with malnutrition. The

student is reviewing the results of the various

laboratory tests performed on the client with the

nursing instructor. Which statement if made by the

nursing student indicates an understanding of the

interpretation of the results?

1. An elevated creatinine level indicates

respiratory problems.2. A normal hemoglobin level indicates that iron

and protein intake is sufficient.

3. An elevated albumin level indicates a definite

dehydration.

4. A normal red blood cell levelindicates

adequate vitamin B6intake

26. The nurse notes that the infant with diagnosis of

hydrocephalus has a head that is heavier than the

average infant. The nurse determines that specialsafety precautions are needed when moving the

infant. Which statement would the nurse include in

the discharge teaching with the parents to reflect

this safety need?

1.When picking up your infant, support the

infants neck and head with the open palm of your

hand.

2.Feed your infant in a side-lying position.

3.Place a helmet on your infant when your in

bed.

4.Hyperextand your infants head with a rolledblanket under the neck area.

27. The nurse is performing an admission

assessment on a child with a seizure disorder. The

nurse is interviewing the childs parents to

determine their adjustment to caring for their child

who has a chronic illness. Which statement if made

by the parents would indicate a need for further

teaching?

1. Our child is involved in a swim program with

neighbors and friends.

2. Our child sleeps in our bedroom at night.3. Our babysitter just completed

cardiopulmonary resuscitation training.

4. We worry about injurieswhen our child has a

seizure.

28. The nurse is reviewing the results of a serum

level drawn from a child who is receiving

carbamazepine(Tegretol) for the control of seizures.

The results indicate a level of 10 mcg/mL. The nurse

analyzes the results and anticipates that thephysician will prescribe.

1. An increase of the dose of the medication.

2. A decrease of the dose of the medication.

3. Discontinuation of the medication.

4. Continuation of the presently prescribed

dosage.

29. The nursing student is asked to describe the

corpus of the uterus. Which of the following

responses, if made by the student, indicates anunderstanding of the anatomy of the uterus?

1.The corpus is the lower portion of the uterus.

2.The corpus is the upper part of the uterus.

3. The corpus is the area where the cervix meet

the external os.

4. The corpus is the area when the vagina meets

the uterus.

30. The nurse instruct the client with diabetes

mellitus about blood glucose monitoring andmonitoring for signs of hypoglycemia. The nurse

informs the client that hypoglycemia is a blood

glucose level of less than

1. 120 mg/dL.

2. 110 mg/dL.

3. 90 mg/dL.

4. 60 mg/dL.


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31. The client newly diagnosed with diabetes

mellitus is instructed by the physician to obtain

glucagon for emergency home use. The client asks

the home care nurse about the purpose of the

medication. The nurse instructs the client that the

purpose of the medication is to treat1.Hypoglycemia from insulin overdose.

2.Hyperglycemia from insufficient insulin.

3.Lipoatrophy from insulin injections.

4.Lipohypertrophy from inadequate insulin

absorption.

32. The nurse is providing care to a Cuban American

client who is terminally ill. Numerous family

members are present most of the time, and many of

the family members are emotional. The mostappropriate action is to

1. Restrict the numbers of family members

visiting at one time.

2. Inform the family that emotional outbursts are

to be avoided.

3. Request permission to move the client to a

private room and allow the family members to visit.

4. Contact the physician to speak to the family

regarding their behaviors.

33. The nurse is instructing a postpartum client with

endometritis about preventing the spread of

infection to the newborn infant. The nurse would tell

the client that

1. Hands should be washed thoroughly before

holding the infant.

2. The newborn infant will not be allowed in the

mothers room at all.

3. There is no danger of the newborn contracting

the disease.

4. Visitors are not allowed to hold the baby.

34. A client presents to the emergency department

with upper gastrointestinal bleeding and is in

moderate distress. In planning care, which nursing

action would be the first priority for this client?

1.Thorough investigation of precipitating events

2.Insertion of a nasogastric tube and hematest of

emesis

3.Complete abdominal examination

4.Assessment of vital signs.

35. The nurse is caring for a client with possible

cholelithiasis who is being prepared for an

intravenous cholangiogram, and the nurse teaches

the client about the procedure. Which client

statement indicates that the client understands the

purpose of this test?

1.They are going to look at my gallbladder and

ducts.

2.This procedure will drain my gallbladder.

3.My gallbladder will be irrigated.4.They will put medication in my gallbladder.

36. The nurse provides instructions to a

malnourished client regarding iron supplementation

during pregnancy. Which statement if made by the

client would indicate an understanding of the

instructions?

1.The iron is best absorbed if taken with orange

juice.

2.Meat does not provide iron and should beavoided.

3.Iron supplements will give me diarrhea.

4.My body has all the iron it needs, and I dont

need to take supplements.

37. The nurse has give discharge instructions to the

client who has underwent vain ligation and stripping

early in the day. The nurse evaluates that the client

understands activity and positioning limitations if

the client states that it is most appropriate to1. Lie down with the legs elevated and avoid

sitting.

2. Cross the legs at the ankle only, but not at the

knee.

3. Sit in the chair 3 times a day for 3 hours at a

time.

4. Walk upright for as much as possible each day.


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38. Octreotide acetate (Sandostatin) is prescribed for

the client with acromegaly. The nurse monitors the

client, knowing that which side effect is associated

with the administration of this medication?

1. Constipation

2. Polyuria3. Abdominal pain

4. Hypotension

39. Levothyroxine (Synthroid) is prescribed for a

client diagnosed with hypothyroidism. The nurse

reviews the clients records and notes that the client

presently is taking warfarin (Caumadin). The nurse

contacts the physician, anticipating that the

physician will prescribe which of the following?

1. An increased dosage of warfarin.2. A decreased dosage of warfarin.

3. An increased dosage of levothyroxine.

4. A decreased dosage of levothyroxine.

40. The nurse is teaching the client with emphysema

about positions that help breathing during dyspneic

episodes. The nurse instruct the client to avoid

which of the following positions, which will

aggravate breathing?

1. Sitting up with the elbows resting on the knees2. Standing and leaning against the wall

3. Lying on the back in low Fowlers position

4. Sitting up and leaning on a table

41. The client is about to undergo a lumbar

puncture. The nurse describes to the client that

which of the following positions will be used during

the procedure?

1. Side-lying with the legs pulled up

2.3.

4.

Comprehensive Review of the Nclex by Saunders 3rd Ed.

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