Nursing: its more than a job

What it takes to be a Nurse

NCLEX 5

1. The nurse is discussing nutritional requirements

with the parents of an 18 month-old child. Which of

these statements about milk consumption is correct?

A) May drink as much milk as desired

B) Can have milk mixed with other foods

C) Will benefit from fat-free cow's milk

D) Should be limited to 3-4 cups of milk daily

The correct answer is D: Should be limited to 3-4 cups

of milk daily

More than 32 ounces of milk a day considerably limits

the intake of solid foods, resulting in a deficiency

of dietary iron, as well as other nutrients.

2. A nurse is doing preconception counseling with a

woman who is planning a pregnancy. Which of the

following statements suggests that the client

understands the connection between alcohol consumption

and fetal alcohol syndrome?

A) "I understand that a glass of wine with dinner

is healthy."

B) "Beer is not really hard alcohol, so I guess I

can drink some."

C) "If I drink, my baby may be harmed before I know

I am pregnant."

D) "Drinking with meals reduces the effects of

alcohol."

The correct answer is C: "If I drink, my baby may be

harmed before I know I am pregnant."

Alcohol has the greatest teratogenic effect during

organogenesis, in the first weeks of pregnancy.

Therefore women considering a pregnancy should not

drink.

3. Immediately following an acute battering incident

in a violent relationship, the batterer may respond to

the partner’s injuries by

A) seeking medical help for the victim's injuries

B) minimizing the episode and underestimating the

victim’s injuries

C) contacting a close friend and asking for help

D) being very remorseful and assisting the victim

with medical care

The correct answer is B: minimizing the episode and

underestimating the victim’s injuries

Many batterers lack an understanding of the effects of

their behavior on the victim and use excessive

minimization and denial.

4. The nurse enters a 2 year-old child's hospital room

in order to administer an oral medication. When the

child is asked if he is ready to take his medicine, he

immediately says, "No!". What would be the most

appropriate next action?

A) Leave the room and return five minutes later and

give the medicine

B) Explain to the child that the medicine must be

taken now

C) Give the medication to the father and ask him to

give it

D) Mix the medication with ice cream or applesauce

The correct answer is A: Leave the room and return

five minutes later and give the medicine

Since the nurse gave the child a choice about taking

the medication, the nurse must comply with the

child''s response in order to build or maintain trust.

Since toddlers do not have an accurate sense of time,

leaving the room and coming back later is another

episode to the toddler.

5. In planning care for a child diagnosed with minimal

change nephrotic syndrome, the nurse should understand

the relationship between edema formation and

A) increased retention of albumin in the vascular

system

B) decreased colloidal osmotic pressure in the

capillaries

C) fluid shift from interstitial spaces into the

vascular space

D) reduced tubular reabsorption of sodium and water

The correct answer is B: decreased colloidal osmotic

pressure in the capillaries

The increased glomerular permeability to protein

causes a decrease in serum albumin, which results in

decreased colloidal osmotic pressure.

6. The school nurse suspects that a third grade child

might have attention deficit hyperactivity disorder

(ADHD). Prior to referring the child for further

evaluation, the nurse should

A) observe the child's behavior on at least 2

occasions

B) consult with the teacher about how to control

impulsivity

C) compile a history of behavior patterns and

developmental accomplishments

D) compare the child's behavior with classic signs

and symptoms

The correct answer is C: compile a history of behavior

patterns and developmental accomplishments

A complete behavioral, and developmental history plays

an important role in determining the diagnosis.

7. A client with emphysema visits the clinic. While

teaching about proper nutrition, the nurse should

emphasize that the client should

A) eat foods high in sodium to increase sputum

liquefaction

B) use oxygen during meals to improve gas exchange

C) perform exercise after respiratory therapy to

enhance appetite

D) cleanse the mouth of dried secretions to reduce

risk of infection

The correct answer is B: use oxygen during meals to

improve gas exchange

Clients with emphysema breathe easier when using

oxygen while eating.

8. In evaluating the growth of a 12 month-old child,

which of these findings would the nurse expect to be

present in the infant?

A) Increased 10% in height

B) 2 deciduous teeth

C) Tripled the birth weight

D) Head > chest circumference

The correct answer is C: Tripled the birth weight

The infant usually triples his birth weight by the end

of the first year of life. Height usually increases by

50% from birth length. A 12 month- old child should

have approximately 6 teeth. ( estimate number of teeth

by subtracting 6 from age in months, ie 12 – 6 = 6).

By 12 months of age, head and chest circumferences are

approximately equal.

9. The nurse, assisting in applying a cast to a client

with a broken arm, knows that the

A) cast material should be dipped several times

into the warm water

B) cast should be covered until it dries

C) wet cast should be handled with the palms of

hands

D) casted extremity should be placed on a

cloth-covered surface

The correct answer is C: wet cast should be handled

with the palms of hands

Handle cast with palms of the hands and lift at 2

points of the extremity. This will prevent stress at

the injury site and pressure areas on the cast.

10. The nurse is assigned to a client who has heart

failure . During the morning rounds the nurse sees the

client develop sudden anxiety, diaphoresis and

dyspnea. The nurse auscultates, crackles bilaterally.

Which nursing intervention should be performed first?

A) Take the client's vital signs

B) Place the client in a sitting position with legs

dangling

C) Contact the health care provider

D) Administer the PRN antianxiety agent

The correct answer is B: Place the client in a sitting

position with legs dangling

Place the client in a sitting position with legs

dangling to pool the blood in the legs. This helps to

diminish venous return to the heart and minimize the

pulmonary edema. The result will enhance the client’s

ability to breathe. The next actions would be to

contact the heath care provider, then take the vital

signs and then the administration of the antianxiety

agent.

11. The nurse prepares for a Denver Screening of a 3

year-old child in the clinic. The mother asks the

nurse to explain the purpose of the test. What is the

nurse’s best response about the purpose of the Denver?

A) "It measures a child’s intelligence."

B) "It assesses a child's development."

C) "It evaluates psychological responses."

D) " It helps to determine problems."

The correct answer is B: "It assesses a child''s

development."

The Denver Developmental Test II is a screening test

to assess children from birth through 6 years in

personal/social, fine motor adaptive, language and

gross motor development. A child experiences the fun

of play during the test.

12. The nurse is monitoring the contractions of a

woman in labor. A contraction is recorded as beginning

at 10:00 A.M. and ending at 10:01 A.M. Another begins

at 10:15 A.M. What is the frequency of the

contractions?

A) 14 minutes

B) 10 minutes

C) 15 minutes

D) Nine minutes

The correct answer is C: 15 minutes

Frequency is the time from the beginning of one

contraction to the beginning of the next contraction.

13. Which of these parents’ comments about a newborn

would most likely reveal an initial finding of a

suspected pyloric stenosis?

A) "I noticed a little lump a little above the

belly button."

B) "The baby seems hungry all the time."

C) "Mild vomiting turned into vomiting that shot

across the room."

D) "We notice irritation and spitting up

immediately after feedings."

The correct answer is C: "Mild vomiting turned into

vomiting that shot across the room."

Mild regurgitation or emesis that progresses to

projectile vomiting is a pattern associated with

pyloric stenosis as an initial finding. The other

findings are present, though not immediately.

14. A client who has been drinking for five years

states that he drinks when he gets upset about

"things" such as being unemployed or feeling like life

is not leading anywhere. The nurse understands that

the client is using alcohol as a way to deal with

A) recreational and social needs

B) feelings of anger

C) life’s stressors

D) issues of guilt and disappointment

The correct answer is C: life’s stressors

Alcohol is used by some people to manage anxiety and

stress. The overall intent is to decrease negative

feelings and increase positive feelings, but substance

abuse itself eventually increases negative feelings.

15. The nurse would expect the cystic fibrosis client

to receive supplemental pancreatic enzymes along with

a diet

A) high in carbohydrates and proteins

B) low in carbohydrates and proteins

C) high in carbohydrates, low in proteins

D) low in carbohydrates, high in proteins

The correct answer is A: high in carbohydrates and

proteins

Provide a high-energy diet by increasing

carbohydrates, protein and fat (possibly as high as

40%). A favorable response to the supplemental

pancreatic enzymes is based on tolerance of fatty

foods, decreased stool frequency, absence of

steatorrhea, improved appetite and lack of abdominal

pain.

16. A client is receiving nitroprusside IV for the

treatment of acute heart failure with pulmonary edema.

What diagnostic lab value should the nurse monitor

when a client is receiving this medication?

A) Potassium level

B) Arterial blood gasses

C) Blood urea nitrogen

D) Thiocyanate

The correct answer is D: Thiocyanate

Thiocyanate levels rise with the metabolism if

nitroprusside is taken, and this can cause cyanide

toxicity. Thiocyanate should not be over 1

millimole/liter.

17. A nurse is assigned to a client who is newly

admitted for treatment of a frontal lobe brain tumor.

Which history offered by the family members would be

recognized by the nurse as associated with the

diagnosis, and communicated to the provider?

A) "My partner's breathing rate is usually below

12."

B) "I find the mood swings and the change from a

calm person to being angry all the time hard to deal

with."

C) "It seems our sex life is nonexistent over the

past 6 months."

D) "In the morning and evening I hear complaints

that reading is next to impossible from blurred

print."

The correct answer is B: "I find the mood swings and

the change from a calm person to being angry all the

time hard to deal with."

The frontal lobe of the brain controls affect,

judgment and emotions. Dysfunction in this area

results in findings such as emotional lability,

changes in personality, inattentiveness, flat affect

and inappropriate behavior.

18. A Hispanic client in the postpartum period refuses

the hospital food because it is "cold." The best

initial action by the nurse is to

A) have the unlicensed assistive personnel (UAP)

reheat the food if the client wishes

B) ask the client what foods are acceptable or are

unacceptable

C) encourage her to eat for healing and strength

D) schedule the dietitian to meet with the client

as soon as possible

The correct answer is B: ask the client what foods are

acceptable or are unacceptable

Many Hispanic women subscribe to the balance of hot

and cold foods in the post partum period. What defines

"cold" can best be explained by the client or family.

19. The nurse is preparing a 5 year-old for a

scheduled tonsillectomy and adenoidectomy. The parents

are anxious and concerned about the child's reaction

to impending surgery. Which nursing intervention would

best prepare the child?

A) Introduce the child to all staff the day before

surgery

B) Explain the surgery 1 week prior to the

procedure

C) Arrange a tour of the operating and recovery

rooms

D) Encourage the child to bring a favorite toy to

the hospital

The correct answer is B: Explain the surgery 1 week

prior to the procedure

A 5 year-old can understand the surgery, and should be

prepared well before the procedure. Most of these

procedures are "same day" surgeries and do not require

an overnight stay.

20. Based on principles of teaching and learning, what

is the best initial approach to pre-op teaching for a

client scheduled for coronary artery bypass?

A) Touring the coronary intensive unit

B) Mailing a video tape to the home

C) Assessing the client's learning style

D) Administering a written pre-test

The correct answer is C: Assessing the client''s

learning style

As with any anticipatory teaching, assess the

client''s level of knowledge and learning style first.

21. The nurse is providing instructions to a new

mother on the proper techniques for breast feeding her

infant. Which statement by the mother indicates the

need for additional instruction?

A) "I should position my baby completely facing me

with my baby's mouth in front of my nipple."

B) "The baby should latch onto the nipple and

areola areas."

C) "There may be times that I will need to manually

express milk."

D) " I can switch to a bottle if I need to take a

break from breast feeding."

The correct answer is D: " I can switch to a bottle if

I need to take a break from breast feeding."

Babies adapt more quickly to the breast when they are

not confused about what is put into their mouths and

its purpose. Artificial nipples do not lengthen and

compress the way the human nipples (areola) do. The

use of an artificial nipple weakens the baby''s suck

as the baby decreases the sucking pressure to slow

fluid flow. Babies should not be given a bottle during

the learning stage of breast feeding.

22. The client who is receiving enteral nutrition

through a gastrostomy tube has had 4 diarrhea stools

in the past 24 hours. The nurse should

A) review the medications the client is receiving

B) increase the formula infusion rate

C) increase the amount of water used to flush the

tube

D) attach a rectal bag to protect the skin

The correct answer is A: review the medications the

client is receiving

Antibiotics and medications containing sorbitol may

induce diarrhea.

23. A client is admitted with a diagnosis of hepatitis

B. In reviewing the initial laboratory results, the

nurse would expect to find elevation in which of the

following values?

A) Blood urea nitrogen

B) Acid phosphatase

C) Bilirubin

D) Sedimentation rate

The correct answer is C: Bilirubin

In the laboratory data provided, the only elevated

level expected is bilirubin. Additional liver function

tests will confirm the diagnosis.

24. The nurse is performing an assessment on a child

with severe airway obstruction. Which finding would

the nurse anticipate?

A) Retractions in the intercostal tissues of the

thorax

B) Chest pain aggravated by respiratory movement

C) Cyanosis and mottling of the skin

D) Rapid, shallow respirations

The correct answer is A: Retractions in the

intercostal tissues of the thorax

Slight intercostal retractions are normal, however in

disease states, especially in severe airway

obstruction, retractions become extreme.

25. The father of an 8 month-old infant asks the nurse

if his child's vocalizations are normal for his age.

Which of the following would the nurse expect at this

age?

A) Cooing

B) Imitation of sounds

C) Throaty sounds

D) Laughter

The correct answer is B: Imitation of sounds

Imitation of sounds such as "da-da" is expected at

this time.

26. During the evaluation phase for a client, the

nurse should focus on

A) All finding of physical and psychosocial

stressors of the client and in the family

B) The client's status, progress toward goal

achievement, and ongoing re-evaluation

C) Setting short and long-term goals to insure

continuity of care from hospital to home

D) Select interventions that are measurable and

achievable within selected timeframes

The correct answer is B: The client''s status,

progress toward goal achievement, and ongoing

re-evaluation

The evaluation step of the nursing process focuses on

the client''s status, progress toward goal achievement

and ongoing re-evaluation of the plan of care. The

other possible answers focus on other steps of the

nursing process.

27. The nurse should recognize that physical

dependence is accompanied by what findings when

alcohol consumption is first reduced or ended?

A) Seizures

B) Withdrawal

C) Craving

D) Marked tolerance

The correct answer is B: Withdrawal

The early signs of alcohol withdrawal develop within a

few hours after cessation or reduction of alcohol

intake. Seizure activity is one withdrawal symptom but

there are many others, like nausea and tremor.

28. The nurse is talking with a client. The client

abruptly says to the nurse, "The moon is full.

Astronauts walk on the moon. Walking is a good health

habit." The client’s remarks most likely indicate

A) neologisms

B) flight of ideas

C) loose associations

D) word salad

The correct answer is C: loose associations

Though the client’s statements are not typical of

logical communication, remarks 2 and 3 contain

elements of the preceding sentence (moon, walk).

Option A refers to making up words that have personal

meaning to the client, and option B – flight of ideas

defines nearly continuous flow of speech, jumping from

one unconnected topic to another. Option D – word

salad refers to stringing together real words into

nonsense “sentences” that have no meaning for the

listener.

29. A 4 year-old child is recovering from chicken pox

(varicella). The parents would like to have the child

return to day care as soon as possible. In order to

ensure that the illness is no longer communicable,

what should the nurse assess for in this child?

A) All lesions crusted

B) Elevated temperature

C) Rhinorrhea and coryza

D) Presence of vesicles

The correct answer is A: All lesions crusted

The rash begins as a macule, with fever, and

progresses to a vesicle that breaks open and then

crusts over. When all lesions are crusted, the child

is no longer in a coIn taking the history of a

pregnant woman, which of the following would the nurse

recognize as the primary contraindication for breast

feeding?

30. In taking the history of a pregnant woman, which

of the following would the nurse recognize as the

primary contraindication for breast feeding?

A) Age 40 years

B) Lactose intolerance

C) Family history of breast cancer

D) Use of cocaine on weekends

The correct answer is D: Use of cocaine on weekends

Binge use of cocaine can be just as harmful to the

breast fed newborn as regular use.

31. A victim of domestic violence tells the batterer

she needs a little time away. How would the nurse

expect that the batterer might respond?

A) With acceptance and views the victim’s comment

as an indication that their marriage is in trouble

B) With fear of rejection causing increased rage

toward the victim

C) With a new commitment to seek counseling to

assist with their marital problems

D) With relief, and welcomes the separation as a

means to have some personal time

The correct answer is B: With fear of rejection

causing increased rage toward the victim

The fear of rejection, abandonment, and loss only

serve to increase the batterer’s rage at the partner.

32. The nurse is assessing a child for clinical

manifestations of iron deficiency anemia. Which factor

would the nurse recognize as the cause of the

findings?

A) Decreased cardiac output

B) Tissue hypoxia

C) Cerebral edema

D) Reduced oxygen saturation

The correct answer is B: Tissue hypoxia

When the hemoglobin falls sufficiently to produce

clinical manifestations, the findings are directly

attributable to tissue hypoxia, resulting from a

decrease in the oxygen carrying capacity of the blood.

33. A recovering alcoholic asked the nurse, "Will it

be ok for me to just drink at special family

gatherings?" Which initial response by the nurse would

be best?

A) "A recovering person has to be very careful not

to lose control, therefore, confine your drinking only

to family gatherings."

B) "At your next AA meeting discuss the possibility

of limited drinking with your sponsor."

C) "A recovering person needs to get in touch with

their feelings. Do you want a drink?"

D) "A recovering person cannot return to drinking

without starting the addiction process over."

The correct answer is D: "A recovering person cannot

return to drinking without starting the addiction

process over."

Recovery requires total abstinence from all drugs.

34. An 18 month-old has been brought to the emergency

room with irritability, lethargy over 2 days, dry

skin, and increased pulse. Based upon the evaluation

of these initial findings, the nurse would assess the

child for additional findings of

A) septicemia

B) dehydration

C) hypokalemia

D) hypercalcemia

The correct answer is B: dehydration

Clinical findings of dehydration include lethargy,

irritability, dry skin, and increased pulse.

35. Which of the actions suggested to the registered

nurse (RN) by the practical nurse (PN) during a

planning conference for a 10 month-old infant admitted

2 hours ago with bacterial meningitis would be

acceptable to add to the plan of care?

A) measure head circumference

B) place in airborne isolation

C) provide passive range of motion

D) provide an over-the-crib protective top

The correct answer is A: measure head circumference

In meningitis, assessment of neurological signs should

be done frequently. Head circumference is measured

because subdural effusions and obstructive

hydrocephalus can develop as a complication of

meningitis. The client will have already been on

airborne precautions and crib top applied to the bed

on admission to the unit.

36. The nurse is caring for a toddler with atopic

dermatitis. The nurse should instruct the parents to

A) Dress the child warmly to avoid chilling

B) Keep the child away from other children for the

duration of the rash

C) Clean the affected areas with tepid water and

detergent

D) Wrap the child's hand in mittens or socks to

prevent scratching

The correct answer is D: Wrap the child''s hand in

mittens or socks to prevent scratching

A toddler with atopic dermatitis needs to have

fingernails cut short and covered so the child will

not be able to scratch the skin lesions, thereby

causing new lesions and possibly a secondary

infection.

37. The nurse is planning to give a 3 year-old child

oral digoxin. Which of the following is the best

approach by the nurse?

A) "Do you want to take this pretty red medicine?"

B) "You will feel better if you take your

medicine."

C) "This is your medicine, and you must take it all

right now."

D) "Would you like to take your medicine from a

spoon or a cup?"

The correct answer is D: "Would you like to take your

medicine from a spoon or a cup?"

At 3 years of age, a child often feels a loss of

control when hospitalized. Giving a choice about how

to take the medicine will allow the child to express

an opinion and have some control.

38. A mother asks about expected motor skills for a 3

year-old child. Which of the following would the nurse

emphasize as normal at this age?

A) Jumping rope

B) Tying shoelaces

C) Riding a tricycle

D) Playing hopscotch

The correct answer is C: Riding a tricycle

Coordination is gained through large muscle use. A

child of 3 has the ability to ride a tricycle.

39. A home health nurse is caring for a client with a

pressure sore that is red, with serous drainage, is 2

inches in diameter with loss of subcutaneous tissue.

The appropriate dressing for this wound is

A) transparent film dressing

B) wet dressing with debridement granules

C) wet to dry with hydrogen peroxide

D) moist saline dressing

The correct answer is D: moist saline dressing

This wound is a stage III pressure ulcer. The wound is

red (granulation tissue) and does not require

debridement. The wound must be protected for

granulation tissue to proliferate. A moist dressing

allows epithelial tissues to migrate more rapidly.

40. A postpartum mother is unwilling to allow the

father to participate in the newborn's care, although

he is interested in doing so. She states, "I am afraid

the baby will be confused about who the mother is.

Baby raising is for mothers, not fathers." The nurse's

initial intervention should be what focus?

A) Discuss with the mother sharing parenting

responsibilities

B) Set time aside to get the mother to express her

feelings and concerns

C) Arrange for the parents to attend infant care

classes

D) Talk with the father and help him accept the

wife's decision

The correct answer is B: Set time aside to get the

mother to express her feelings and concerns

Non-judgmental support for expressed feelings may lead

to resolution of competitive feelings in a new family.

Cultural influences may also be clarified.

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