Test Drive — . _. oe First EditionThese materials are solely intended for use as preparation for the Nursing Licensure Examination, NCLEX. It is not a guide to the clinical treatment of patients. Neither the authors nor the publisher shall be responsible for any harm caused by the use of these materials other than for its intended Purpose. These materials are a small portion of the Kaplan materials available for you to prepare for the NCLEX. © 2001 KAPLAN EDUCATIONAL CENTERS All rights reserved. These materials are intended for your personal use. No part of these materials may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval systems, or resold without the written permission of the Publisher, except where permitted by law. Any violation hereof shall Constitute a violation of the United States copyright laws and is subject to prosecution.Test Drive TEST DRIVE EXPLANATIONS 1. Which of the following actions, if performed by | 1. The nurse obtains a Guthrie blood test on a the nurse, would be considered negligence? 4-day-old infant. obtain after ingestion of protein; no later than 7 days after delivery 2. The nurse massages lotion on the abdomen of a 3-year-old diagnosed with Wilm’s tumor. CORRECT - manipulation of mass may cause dissemination of cancer cells 3. The nurse instructs a 5-year-old asthmatic to blow on a pinwheel. exercise that will extend expiratory time and increase expiratory pressure 4, The nurse plays kickball with a 10-year-old with juvenile arthritis (JA). excellent moving and stretching exercise NCLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION . The nurse in the same-day surgery department ‘cares for a 77-year-old woman after a sigmoidoscopy. Which of the following symptoms, if exhibited by the woman an hour after the procedure, would MOST concem the nurse? The client complains of fullness and pressure in her abdomen. expected after this procedure . The client complains of grogginess and thirst. expected after this procedure; has been NPO since midnight before the procedure, Versed is used to aid in relaxation during procedure; Atropine is used during procedure to decrease peristaltic activity . The client complains of theadedness and dizziness. CORRECT - could signity hypovolemic shock due to bowel perforation The client complains of mild pain and cramping in her abdomen. ‘expected after this procedureTest Drive ‘The nurse is discharging a patient from an inpatient alcohol treatment unit. Which of the following statements, if made by the patient's wife, indicates to the nurse that the family is coping adaptively? “My husband will do well as long as | keep him engaged in activities that he likes.” wife is accepting responsibility, codependent behavior “My focus is learning how to live my life.” CORRECT - wife is working to change codependent patterns “1am s0 glad that our problems are behind us." unrealistic; discharge is not the final step of treatment “Vil make sure that the children don't give my husband any problems. wife is accepting responsibility, codependent behavior (NGLEX ~ Test rive Explanations __PREPARATION FOR THE NURSING LICENSURE EXAMINATION Stay with the patient and contact radiology. need to secure the implant in a lead container kept in the patient's room Wrap the implant in a blanket and place it behind the lead shield. pick up implant with long-handled forceps Pick up the implant with long-handled forceps and place it in a lead container. CORRECT — never touch implant with bare hand; forceps and container should be kept in patient's room 4, The nurse is caring for a patient with cervical 1 cancer. The nurse notes that the radium implant has become dislodged. Which of the following actions should the nurse take FIRST? 2. 3. 4 Obtain a dosimeter reading on the patient and report it to the physician. need to place implant in lead container _____ KAPLANTest Drive 5. The nurse has reviewed the charts of four 1. A.22-year-old Oriental women who is antepartal women. Which woman is at greater having a girl. risk for having a child with a cleft lip and palate? individuals of Asian background are more likely to have a child with cleft lip and palate; less likely to be found in a girl 2. A 25-year-old Native American female who is having a boy. CORRECT — Native Americans have the highest incidence of cleft lip and palate; males are more likely than females to have both 3. A6-year-old African American woman who is having a boy. African Americans are least likely to have a child with cleft lip and palate 4, A.40-year-old Caucasian who is having a air. less likely to have a child with cleft lip and cleft palate, more common in males [NGLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE 6. A 22-year-old woman in her second trimester of | 1 pregnancy tells the clinic nurse that her child hhas been asking questions “about sex.” The client asks the nurse what she should tell her “Buy a book about sex designed for young children and read it with your son.” not best action, may provide more information than child is seeking S-year-old son. Which of the following statements, if made by the nurse, is BEST? “Answer your son’s questions in a matter-of-fact manner, in words that he will understand.” CORRECT - helps child understand his concerns, allows for answering exact question that is being asked “Tell your son that this subject is complicated, and you will discuss it with him as he gets older.” questions should be answered as they are asked, not postponed or ignored “Have your son touch your abdomen and tell him about your pregnancy.” doesn't answer particular questions child has; assumes that questions about pregnancy _ KAPLANTest Drive 7. The nurse is observing a LPN/LVN administer iron dextran (DexFerrum) IM. It is MOST important for the nurse to give which of the following instructions? "Massage the injection site for one minute after the injection of the medicine.” causes medication to leak into subcutaneous tissue, staining skin “Tap out the air bubble prior to administering the medication.” draw up 0.2 cc of air to create an airlock “Release the skin prior to withdrawing the needle.” release skin after withdrawing the needle “Change the needle after drawing up the medication.” CORRECT - ensures that no solution remains on outside of needle INGLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION 8. Anurse is caring for clients in the mental health clinic. A woman comes to the clinic ‘complaining of insomnia and anorexia. The patient tearfully tells the nurse that she was laid off from a job that she had held for 15 years. Which of the following responses, if made by the nurse, is MOST appropriate? “Did your company give you a severance package?” yes-no question, nontherapeutic “Focus on the fact that you have a healthy, happy family." gives advice, false reassurance “Tell me what happened.” CORRECT - explore situation. Allows patient to verbalize “Losing a job is common nowadays.” dismisses the patient’s concern KAPLANTest Daive 9. The nurse is teaching a 45-year-old woman how to increase the potassium in her diet. The woman says she knows bananas are high in Potassium, but she doesn't like their taste. What foods should the nurse recommend the client include in her diet? Carrots, broccoli, yogurt. potassium content: carrots 221 mg, broccoli 254 mg, yogurt 251 mg, for a total of 726 mg Rhubarb, tofu, celery. potassium content: rhubarb 548 mg, tofu 9 mg, celery 114 mg, for a total of 671 , spinach, raisins. CORRECT — potatoes 610 mg, spinach 838 mg, raisins 1089 mg, for a total of 2537 mg Onions, com, oatmeal. potassium content: onions 318 mg, corn 192 mg, oatmeal 132 mg, for a total of 642 mg NCLEX ~ Test Drive Explanations __ -PREPARATION FOR THE NURSING LICENSURE EXAMINATION 10. A 68-year-old woman diagnosed with thrombocytopenia due to acute lymphocytic leukemia is admitted to the hospital. The nurse should assign the patient to a private room so she will not infect other Patients and health care workers. poses little or no threat private room so she will not be infected by other patients and health care workers. CORRECT protects patient from xogenous bacteria, risk for developing infection from others due to depressed WBC count, alters ability to fight infection semiprivate room so she will have stimulation during her hospitalization. should be placed in a room alone semiprivate room so she will have the ‘opportunity to express her feelings about her illness. should ensure that patient is provided with opportunities to express feelings. about iliness KAPLANTest DRIVE 1". The nurse cares for a 46-year-old woman after a traditional cholecystectomy. ‘The patient has ‘a nasogastric tube connected to suction, an IV (f DW infusing into her right arm, and a T-tube and Penrose drain in place. The nurse would be MOST concerned by which of the following findings? The systolic blood pressure is 10 mmHg, lower than it was preoperatively. decrease could be due to position change or fluids lost during surgery There is 250 cc of bloody drainage from the T-tube during the first 24 hours. CORRECT — would expect drainage of 400 mV/day with gradual decrease in amount, will be bloody initially and change to greenish-brown There is 30 cc of serosanguineous drainage in he Penrose drain during the first 24 hours. drainage is expected, prevents accumulation of fluid in the incision The patient experiences a 40 degree temperature elevation the evening after surgery. elevation of temperature is expected after surgery INGLEX ~ Test Drive Explanations _PREPARATION FOR THE NURSING LICENSURE EXAMINATION 12, The nurse is leading an inservice about 1 ‘management issues. The nurse would intervene if a nurse made which of the following statements? “itis my responsibilty to ensure that the ‘consent form has been signed and attached to the patient's chart prior to surgery.” describes the nurse's responsit “It is my responsibilty to witness the signature ofthe client before surgery is Performed.” signature indicates that nurse saw the patient sign the form ity ‘It is my responsibility to provide a detailed description of the surgery and ask the patient to sign the consent form. CORRECT ~ physician should provide explanation and obtain signature “itis my responsibilty to answer questions that the patient may have prior to surgery." describes the nurse’s responsibility wo —KAPLANTest Drive 13, ‘A patient with a history of alcoholism is brought to the emergency room in an agitated state. He is vomiting and diaphoretic. He had his last drink five hours ago. The nurse would expect to administer which of the following medications? Chlordiazepoxide hydrochloride (Librium). CORRECT ~ antianxiety; used to treat symptoms of acute alcohol withdrawal; ‘S/E-ethargy, hangover, agranulocytosis Disutfiram (Antabuse). Used as a deterrent to impulsive drinking, contraindicated if patient drank alcohol in previous 12 hours Methadone hydrochloride (Dolophine). Opioid analgesic, used to treat narcotic withdrawal; syndrome, S/E-seizures, respiratory depression Naloxone hydrochloride (Narcan). Narcotic antagonist used to reverse narcotic-induced respiratory depression; S/E-ventricular fibrillation, seizures, pulmonary edema NCLEX ~ Test Drive Explanations -PREPARATION FOR THE NURSING LICENSURE EXAMINATION 14, The nurse is caring for a patient with an acute myocardial infarction. Which of the following laboratory findings would MOST concern the nurse? Erythrocyte sedimentation rate (ESR)- 40 mnvh ESR-rate at which RBCs settle out of unclotted blood in 1 h; indicates inflammation/necrosis; normal: men (0-15/h, women: 1-20 mm/h Hematocrit (Hcl)~42%. relative volume of plasma to RBC; increased in dehydration; decreased with fluid volume excess; normal: men 40-45%, women: 37-45% Creatine kinase (CK)~350 U/ml ‘CORRECT - enzyme specific to brain, myocardium indicate tissue necrosis or injury; en: 12-70 U/mL, women: Serum glucose-100 mg/dL. tes insulin production: normal: 60-110 mg/dL.Test Drive 15. The nurse has completed discharge instructions for a primigravida woman at 29 weeks gestation who is hospitalized for treatment of deep vein thrombosis. Which of the following statements, itmade by the patient to the nurse, indicates that teaching has been successful? “1 will give myself heparin every da ‘CORRECT - heparin doesn't cross the placenta; considered safe during pregnancy “1 should check my leg once a week.” not an aspect of self-care “Iwill message my leg nightly.” contraindicated with DVT; clot can be released “Lean take Pepto-Bismol for diarrhea." increases the anticoagulant effect, don’t use together NCLEX ~ Test Drive Explanations __PREPARATION FOR THE NURSING LICENSURE Ex AMINATION clinic. The nurse would be MOST concerned if which of the following was observed? 16. The nurse is caring for clients in an orthopedic | [— A teenager who is 6'4” tall places the crutches about 6” to the side of his feet when ambulating with crutches. CORRECT - taller person requires a broader base of support ‘A school-aged child who is 4'8” tall flexes, her elbows about 20 degrees when ambulating with crutches. elbows flexed 20-30 degrees enables correct hand placement on grips A middle-aged adutt, 510" tall, advances the crutches first when walking down the stairs. appropriate technique, follow crutches with weak leg, then strong leg ‘An older adult, 56" tall, uses a 4-point gait ‘when ambulating with crutches. provides maximum support partial ‘weight bearing both feet requiredTest Drive 7. At the advice of the physician, a client with hypertension attends classes to help him quit smoking. One month later the client visits the clinic, and the nurse notes a package of Cigarettes in his pocket. Which of the following statements, if made by the nurse, is MOST appropriate? see that you have cigarettes CORRECT - encourages client to verbalize issues and concerns your 2. “Please give me the cigarettes.” authoritarian 3. “Tl have to report this to the physician.” no need to involve physician 4, "You'll have to enroll in another class.” need to find out more information before determining a course of action NCLEX ~ Test Drive Explanations.___ 1PREPARATION FOR THE NURSING LICENSURE EXAMINATION 18. A65-year-old woman recovering from a right below-knee amputation (BKA) asks the nurse why the bandage is applied in a “figure-eight.” Which of the following explanations, if made by the nurse, is MOST accurate? "It decreases the possibly of infection.” antibiotics first 48-72 h do this “It helps to minimize postoperative pain.” not primary purpose “it reduces the possibilty of clot formation. inaccurate “It reduces postoperative swellin: CORRECT — hastens venous return, controls edema; must be worn at ali times except bathing; must be removed and reapplied several times a day KAPLANTest Drive 19. While inserting a nasogastric tube, the nurse should use which of the following protective measures? Gloves, gown, goggles, and a surgical cap. surgical caps offer protection to hair, but aren't required Sterile gloves, mask, plastic bags, and gowns. plastic bags provide and aren't part of uni 10 direct protection sal precautions Gloves, gown, mask, and goggles. CORRECT - must use universal Precautions on all patients; prevent skin and mucous-membrane exposure when contact with blood or other body fluids is anticipated Double gloves, goggles, mask, and surgical cap. only partially correct; surgical caps not required; unnecessary to double glove NCLEX ~ Test Drive Explanations.PREPARATION FOR THE NURSING LICENSURE EXAMINATION 20. ‘The physician orders codeine 60 mg and aspirin grains X PO every four hours, as ‘needed for pain. Each codeine tablet contains 15 mg of codeine. Each aspirin tablet contains 325 mg of aspirin. Which of the following should the nurse administer? 2 codeine tablets and 4 aspirin tablets. inaccurate 4 codeine tablets and 3 aspirin tablets. inaccurate 4 codeine tablets and 2 aspirin tablets. CORRECT ~ 60/x = 15/1, x = 4, 10 grains = 600 mg; 325/1 = 600/x, x 8 codeine tablets and 3 aspirin tablets. inaccurate KAPLANTest Drive 21 ‘The nurse is caring for a patient 4 hours after undergoing intracranial surgery. Which of the following actions should the nurse take immediately? ‘Tum, cough, and deep-breathe the patient. coughing discouraged, can increase intracranial pressure Place the patient with his neck flexed and head turned to the side. will increase ICP; keep head in a neutral position Perform passive range of motion exercises. changes in the patient's position can increase the intracranial pressure Move the client to the head of the bed using a turning sheet. CORRECT ~ patient's body should be moved as a unit to prevent increased ICP; prevent disruption of the ICP monitoring system [NGLEX ~ Test Drive Explanations _PREPARATION FOR THE NURSING LICENSURE EXAMINATION 22. The nurse observes the behavior of a patient 1. Behavioral disorganization, inability to seen in the emergency room. Which of the negotiate simple life demands, increased following would indicate to the nurse that the ability to concentrate. patient is experiencing a panic level of anxiety? will have decreased ability to concentrate 2. Heightened sensory awareness, impaired ‘cognitive function, distorted perception. sensory input is decreased with panic 3. Increased pulse, increased muscle tension, rate of speech and volume are adequate for ‘communication. pulse, muscle tension, rate of speech and volume all increase with panic 4, Reduced sensory input, distorted perception, behavioral disorganization. CORRECT KAPLAN23, A7-year-old git with insulin-dependent diabetes (IDDM) has been home sick for several days and is brought to the emergency department by her parents. A diagnosis of ketoacidosis is made. The nurse would expect to see which of the following lab results for this client? ‘Serum glucose 140 mg/dL. normal 70-120 mg/dL; would expect it to be dangerously high ‘Serum creatine 5.2 mg/d. normal 0.61.2 mg/dL; indicates kidney disorders, not seen with ketoacidosis Blood pH 7.28. CORRECT — normal 7.35-7.45, indicates acidosis Hematocrit 38%. normal male 41-53%; female 36-46%; would expect it to be normal or high due to dehydration [NGLEX ~ Test Drive Explanations _PREPARATION FOR THE NURSING LICENSURE EX AMINATION 24, The nurse in the newborn nursery has just received report. Which of the following infants should the nurse see first? ‘A two-day-old infant is lying quietly alert with a heart rate of 185. ‘CORRECT - infant has tachycardia; requires further investigation; normal resting rate is 120-160 ‘A one-day-old infant is crying and the anterior fontanel is bulging. crying causes increased intracranial pressure, which causes the fontanel to bulge ‘A 12-hour-old infant is being held and the respirations are 45 breaths per minute and irregular. normal respiratory rate is 30-60 breaths per minute with apneic episodes A five-hour-old infant is sleeping and the hands and feet are blue bilaterally. acrocyanosis is normal for 2-6 hours postdelivery due to poor peripheral circulation_— Test Drive 25. The nurse in the outpatient clinic is discussing exercise programs with a group of adults. Which of the following statements, if made to the nurse by one of the participants, indicates the need for further teaching? “I should individualize my exercise program to meet my needs.” programs should be individualized “I should incorporate the exercise program into my daily activities.” this makes it part of daily routine “I should maintain consistent participation in my exercise program.” needs to participate in exercise program on consistent basis “| should perform vigorous exercise several times a week.” INCORRECT ~ exercise need not be vigorous; should increase resting heart rate INGLEX ~ Test Drive Explanations ___PREPARATION FOR THE NURSING LICENSURE EXAMINATION 26. The nurse in the outpatient clinic evaluates the Mantoux test of a 36-year-old woman. The woman's history indicates that she has been treated during the past year for an AIDS-related infection. The nurse should document that there was a positive reaction if there was an area of induration measuring what? 7mm. CORRECT - greater than 5 mm area positive for patient with HIV-infection history 11mm. area of 10 mm or more indicates a positive reaction for a patient without an HIV infection 15 mm. greater than 5 mm area positive for Patient with HIV infection history KAPLANTest Drive 27. The nurse is performing a home care visit on a three-year-old with a cast on the left arm due to a fracture of the radius. The nurse would be MOST concemed if which of the following was observed? The mother wraps the cast with plastic wrap prior to bathing the child. will waterproof cast against splashes; keep cast should be kept out of water The child elevates the left arm on a pillow While watching television. will prevent swelling; can support with a sling oF on pillow . The child is sitting at the table coloring in a coloring book. CORRECT — possibility of child trom sticking small items down cast The mother encourages the child to wiggle the fingers on the left hand. indicates good circulation; also check for swelling, discoloration, or decreased sensation NCLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION. 28. The home care nurse is visiting an 82-year-old ‘woman living with her daughter. The client appears malnourished and has multiple bruises ‘on her body. Which of the following actions, if taken by the nurse, is MOST appropriate? Place a home health aide with the patient to document incidents of abuse. must report suspected cases Report the situation to the nursing supervisor. CORRECT - required by state law Discuss the nurse's observation with the client's children. report to the nursing supervisor Request that another nurse visit the patient "to assess the situation. no reason to involve another nurse KAPLANTest Daive 29. The nurse is caring for a 7 Ib 9 07 infant bor 24-hours ago by cesarean section due to ‘maternal herpes simplex virus. It would be MOST important for the nurse to take which of the following actions? Wear gloves when caring for the infant. CORRECT - inspect eyes, mouth, and skin for lesions Administer immune globulin, infant treated with vidarabine or acyclovir if indicated Place the infant in isolation. no reason to isolate infant; gloves worn during care Encourage the mother to bottle feed the infant. can breast feed if no suspicious lesion Present on the mother's breast [NGLEX ~ Test Drive Explanations.PREPARATION FOR THE NURSING LICENSURE EXAMINATION 30. The nurse plans to teach a 52-year-old woman about warfarin sodium (Coumadin). The nurse should teach the patient which of the following measures? To increase her daily intake of green leafy vegetables. cabbage, cauliflower, broccoli, asparagus, lettuce, onions, turnip greens, fish, and liver contain vitamin K; would decrease effect of medication; smoking increases required dose; flu vaccine enhances effect for 1 month; fever, prolonged hot weather enhances efte To test her stools weekly for blood. no need to check this often; should observe for blood To wear a Medic Alert bracelet. CORRECT — provides for safety; should have PT check q 1-4 weeks; also teach to use soft tooth brush and electric razor To stop taking the Coumadin before going to the dentist. ‘should continue to take but tell the dentist___ Test Drive ‘31. The nurse is caring for a patient one day after | 1. Discontinue the nasogastric tube. an abdominal-perineal resection for cancer of isconti the rectum. The nurse should question which = pee Sie Es of the following orders? 2. Itrigate the colostomy. CORRECT - colostomy begins to function 3-6 days after surgery 3. Place petrolatum gauze over the stoma. done if no pouch in place, keeps stoma moist, cover with dry, sterile dressing 4, Administer Demerol 50 mg IM for pain. Prevent postop pain NCLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION 32. The nurse plans postoperative care for a 40- year-old woman scheduled for a stapedectomy. ‘When the patient is returned to her room after surgery, the nurse should expect which of the following? Patient's hearing is completely restored. initially worse; improves after 6 weeks Patient is still drowsy from the general anesthesia. local anesthetic used Patient has drains in both ears. not used; gel foam (absorbent sponge) packing used to decrease bleeding Patient experiences vertigo, nausea, and vomiting. CORRECT — close to inner ear; {anti-vertigo) and Compazine (antiemetic) used; assist with ambulation, side rails up, change positions slowly Antivert — KAPLANTest Drive 33. The nurse is observing a student nurse care for patient with a tracheostomy tube. The nurse should intervene if which of the following is observed? The student nurse uses clean gloves to remove the tracheostomy dressing, appropriate procedure; dispose of solid dressing and gloves appropriately The student nurse cleans the inner canula by soaking it in hydrogen peroxide. appropriate procedure; clean with small brush or pipe cleaner; rinse well in normal saline The student nurse replaces the dressing with a folded gauze 4x 4. use folded 4 x 4 or commercially prepared 4 x 4; do not cut dressing to prevent aspiration 4. ‘The student nurse removes the soiled trach ties then reattaches clean ties. ‘CORRECT — apply new ties prior to removing old ties to prevent dislodgment of the trach [NGLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION. 34. The nurse is caring fora woman at 37 weeks | 1. B/P 150/95. gestation. The nurse would be MOST Concerned by which ofthe following findings? ee seuss 2. 4+ proteinuria. indicates severe preeclampsia The patient c/o right quadrant pain. CORRECT - indicate: function, sign of impen¢ 4, 3* pitting edema of the ankles. dependent edema, indicative of mild preeclampsia APLANTest Drive A t-year-old girl admitted to the hospital with a fractured femur is placed in Bryant's traction. ‘The nurse knows that the child should be placed in which of the following positions? Buttocks slightly elevated off the bed. CORRECT ~ child’s weight provides countertraction Legs elevated at a 45° angle. should be at 90° Knees slightly flexed. not possible; must be extended Hips fully extended. must be flexed at 90° angle NCLEX ~ Test Drive Explanations.PREPARATION FOR THE NURSING LICENSURE EXAMINATION 96. A 72-year-old woman is admitted to a long-term care facility. The client is occasionally confused and her gait is often unsteady. Which of the following actions, if taken by the nurse, is MOST appropriate? ‘Ask the woman’s family to provide personal items such as photos and mementos. CORRECT — provides visual stimulation to reduce sensory deprivation Select a room with a bed by the door so the woman can look down the hall provides only occasional stimulation ‘Suggest the woman eat her meals in the Toom with her roommate. needs to eat in the dining hall with others for stimulation Encourage the woman to ambulate in the halls twice a day. unsafe due to unsteady gait and confusion_Test Drive 37. An 84-year-old man is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tube. An order {or cloth-wrist restraints is received by the nurse. Which of the following actions by the nurse is MOST appropriate? Attach the ties of the restraint to the bed frame. CORRECT - allows the raising and lowering of the side rail without injury to the patient Perform circulation checks to the ‘extremities, that are restrained once a shift. circulation checks should be done every 1-2 hours; vascular injury may result from poor circulation from a restraint that is too tight Remove the restraints when the patient is Up in a wheelchair. restraints should be secured when the patient is at risk for harm to himself and is unattended; should be removed every hours and skin assessed and area massaged; patient should not be left unattended when restraint is removed for care Explain the need for the restraints only to the family. restraints can increase confusion or ‘combativeness of the patient; patient and family should receive explanation for the restraint, the type of restraint, and the anticipated duration of use NGLEX ~ Test Drive Explanations _PREPARATION FOR THE NURSING LICENSURE EXAMINATION. 38. The nurse cares for a patient who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessments would the nurse find consistent with this diagnosis? Urinary output of 2,500 cc/24 hours, sodium 122 mEq. increased ur serum sodium Urinary output of 800 ce/24 hours, sodium 156 mEgiL. decreased urine output; increased serum sodium Urinary output of 2,700 ce/24 hours, sodium 164 mEQlL. increased urine output; increased serum ‘sodium; diabetes insipidus due to lack of ADH; symptoms-polyuria, polydipsia; treatment-vasopressin (Pitressin) output; decreased Urinary output of 500 cc/24 hours, sodium 118 mEq/L. CORRECT — decreased urine output; decreased serum sodium; hyponatremia with normal or increased plasma volume KAPLAN39. A 25-year-old man is being treated for Pneumocystis carinii pneumonia, The nurse should intervene in which of the following situations? ‘housekeeper cleans up spilled blood with ‘bleach solution. appropriate activity, solution of 1:10 5.25% sodium hypochlorite or bleach with water, kills AIDS virus ‘A nursing student takes the patient's, blood pressure wearing a mask and gloves. ‘CORRECT — mask and gloves not necessary, only needed when possibility of contact with blood and body fluids; when taking a BP very low risk for contact with blood and body fluids; behavior insensitive to patient's, feelings, does not promote trust technician wears gloves to perform a venipuncture, ‘safe practice, barrier precaution used to prevent skin and mucous membrane ‘exposure if contact with blood or body fluids of any patient anticipated ‘Annurse attendant allows visitors to enter his room without masks. appropriate activity, visitors do not need masks; PCP parasite found in lungs of healthy people, thought to cause subclinical pulmonary infection ‘worldwide, only dangerous to immunosuppressed patients; sick people not permitted to visit patient INCLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION 40. A 14-year-old boy is brought to the emergency | 1. Dsin water. room with a compound fracture of the left femur. His vital signs are: BP 80/60, pulse 120, respirations 26, temperature 99.0° F (37.2° C). Which of the following fluids would the nurse expect the physician to order initially? need isotonic fluid, not hypotonic fluid Ds in 0.45% NaCl. not best fluid in this situation 0.45% NaCl. this is hypotonic solution, isotonic fluid is needed at this time Lactated Ringer's. CORRECT ~ need isotonic fluid to restore circulating blood volume, may also use 0.9% NaCl KAPLANTest DRive a ‘The nurse is observing a staff member assist the physician with a lumbar puncture. The ‘nurse would determine that the care was appropriate if the nurse observed which of the following behaviors? ‘The nurse assists the patient into a fetal position. CORRECT — the client uses his/her arms to hold knees in place, head bent forward; increases space between vertebrae ‘The nurse instructs the patient to maintain a full bladder. patient should empty bladder for comfort ‘The nurse explains to the patient that he won't be able to feel anything during the procedure. patient will feel a needle prick or may feel pain in the leg ‘The nurse instructs the patient to hyperventiate. patient should breathe normally; hyperventilation may lower an elevated pressure NCLEX ~ Test Drive Explanations,PREPARATION FOR THE NURSING LICENSURE EXAMINATION 42, Which of the following observations of an 8 Ib 1. The infant's respirations are 36, shallow 4.02 newbom boy, if made by the nurse, would and irregular in rate, rhythm, and depth. eaulre on imerveniony normal due to immaturity of respiratory system 2. The infant's 96.2" F (35. ‘CORRECT — subnormal indicates prematurity, infection, low environment temperature, inadequate clothing, dehydration 3. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line normal, site of apical pulse, normal rate 120-140 bpm 4, There is asynchronous spontaneous movement of the infant's extremities. normal, legs move in bicycle fashion, should have equal extension of all KAPLANTest Drive 43. To evaluate a patient's hydration status, the ‘nurse should check the patient’s erythrocyte sedimentation rate (ESR). ESR-rate at which RBCs settle out of unclotted blood in 1h; indicates inflammation/necrosis; normal: men (0-15 mm/h, women: 0-20 mm/h white blood cell count (WBC). WBC-indicates infection (normal 5,000-10,000/mm?); reduced: leukopenia, elevated: leukocytosis hematocrit (Het). ‘CORRECT - relative volume of plasma to RBC; increased with dehydration; decreased with fluid volume excess; normal: men 40-45%, women 37-45: other tests that indicate hydration: BP, tine specific gravity (normal: 4.003—1.030), CVP (normal: 3-11 emH,0) serum glucose. indicates insulin production (normal 60-110 mg/dL) NCLEX ~ Test rive Explanations_PREPARATION FOR THE NURSING LICENSURE EXAMINATION 44, The nurse is caring for a patient one hour after a percutaneous liver biopsy. The nurse would be MOST concerned if which ofthe following was observed? The patient is lying on her right side with a pillow under the costal margin. prevents hemorrhage or escape of bile ‘The patient frequently coughs after deep breathing. CORRECT ~ avoid coughing or straining to prevent hemorrhage ‘The LPN obtains the blood pressure and pulse every 15 minutes. vital signs monitored q 10-15 min during first hour and q 30 min for next 1-2 hours; assess for hemorrhage The patient states that she has mild pain radiating to her right shoulder. expected, may also have mild local pain KAPLANTest Drive 45. The nurse knows that which of the following Patients has the lowest risk of developing a ‘deep vein thrombosis (DVT)? ‘A 67-year-old carpenter undergoing a left total knee replacement. age, surgery (up to 70% experience DVT a8 a complication), and immobility put him at risk ‘A 22-year-old woman who weighs 290 Ib and is 2 months pregnant with her second child. obesity and pregnancy put her at risk ‘A 44-year-old woman with ovarian cancer experiencing vomiting from chemotherapy. cancer and dehydration put her at risk A 50-year-old executive following removal of cataracts. CORRECT - age increases risk but patient is usually not immobile after cataract surgery INCLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION 46. The nurse is caring for a 67-year-old man four days after a suprapubic prostatectomy. The physician has removed the Foley catheter. A suprapubic (S/P) catheter remains in place. Which of the following actions, if taken by the nurse, is MOST appropriate? Encourage the patient to void; measure the ‘amount of urine voided and drained from the suprapubic catheter; document the results. will not give correct assessment of residual urine in bladder Clamp the suprapubic catheter for two hours, release the clamp, allow it to drain to gravity; measure and document the results. will not give correct assessment of residual urine in bladder Encourage the patient to void every two hours with the suprapubic catheter ‘clamped; open the clamp, allow the catheter to drain to gravity, and document the results. will not give correct assessment of residual urine in bladder Clamp the suprapubic catheter; have the patient void; unclamp the catheter, and allow it to drain to gravity; measure and document the results, CORRECT — checks for residual in the bladder after voiding; when residual urine is 75 ml or less the S/P catheter is usually removed KAPLANTest Daive 47. Anurse is supervising a group of elderly clients ina residential home setting. The nurse knows the elderly are at greater risk of developing sensory deprivation for what reason? Increased sensitivity to the side effects of medications. many medications alter Gl functioning but do not cause decreased vision, hearing, or taste Decreased visual, auditory, and gustatory abilities CORRECT — gradual loss of sight, hearing, and taste interferes with normal functioning Isolation from thelr families and familiar surroundings. clients are in contact with other residents and staff who provide stimulation Decreased musculoskeletal function and mobility. they can be placed in wheelchairs and moved [NGLEX ~ Test Drive Explanations __PREPARATION FOR THE NURSING LICENSURE EXAMINATION 48. 67-year-old patient with emphysema 5 becomes restless and confused. Which of the 1. Encourage the patient to perform following actions, if taken by the nurse, is pursed lip breathing. BEST? CORRECT - prevents collapse of lung unit, and helps patient control rate and depth of breathing 2. Check the patient's temperature. confusion is probably due to decreased oxygenation 3. Assess the patient's potassium level. confusion is probably due to decreased ‘oxygenation, not electrolyte imbalance 4, Increase the patient's oxygen flow rate to 5 Umi. ‘should receive low flow oxygen to prevent CO, narcosis KAPLAN49. The nurse is performing discharge teaching on a patient with chronic renal failure. The nurse knows that teaching has been successful i the patient selects which ofthe following menus? 6 02 roast beef, baked potato, 1/2 cup broccoli, one orange, and 16 oz of iced tea. protein and potassium 4.02 baked ham, 1/2 cup potatoes au gratin, 1/2 cup canned green beans, one apple, and 8 02 of milk. ham and canned green bean high in sodium 2oz turkey, 1/2 cup noodles, 1/2 cup carrots, 1/2 cup blueberries, and 8 oz cola. CORRECT — appropriate amount of HBV protein, low potassium fruit, protein-free drink Hot dog with bun, 1/2 cup pork and beans, ‘cup spinach saiad, 1 banana, and 8 oz lemonade. LBV protein, high sodium, high potassium (spinach and banana) [NCLEX ~ Test Drive ExplanationsPREPARATION FOR THE NURSING LICENSURE EXAMINATION 50. The nurse on postpartum is preparing four patients for discharge. It would be MOST important for the nurse to refer which of the following patients for home care? A 15-year-old primipara who delivered a 7 Ib male 2 days ago. stable situation, no indication of problems with mother or baby ‘An 18-year-old multipara who delivered a 9 Ib female by cesarean section 2 days ago. stable patient, no indication of problems with mother or baby ‘A 20-year-old multipara who delivered 1 day ago and is complaining of cramping. stable patient, cramping due to uterine contraction ‘A 22-year-old who delivered by ‘cesarean section and is complaining of burning on urination. CORRECT - unstable patient, indicates urinary tract infection, requires follow- up KAPLAN‘The answer key appears on the following page. INCLEX ~ Test Drive Explanations - Test DrivePREPARATION FOR THE NURSING LICENSURE EXAMINATION NOSANNONON 11. 12. 13. 14, 15. 16. 17. 18. 19. 20. NCLEX TEST DRIVE ANSWER KEY 2 214 31.2 3 22. 4 32. 4 1 23.3 33. 4 3 24.1 34. 3 1 25. 4 35. 1 1 26. 2 36. 1 1 27. 3 37.4 4 28. 2 38. 4 3 29.1 39. 2 3 30. 3 40. 4 a. 42. 43, 44. 45. 46. 47. 48. 49. ROANEENONA KAPLAN