NCLEX RN Practice Exam 12 client with a fractured hip most likely to

1. After the physician performs an exhibit?

amniotomy, the nurse’s first action should A. Pain
be to assess the: B. Disalignment
C. Cool extremity
A. Degree of cervical dilation D. Absence of pedal pulses
B. Fetal heart tones
7. The nurse knows that a 60-year-old
C. Client’s vital signs
D. Client’s level of discomfort female client’s susceptibility to
2. A client is admitted to the labor and osteoporosis is most likely related to:
delivery unit. The nurse performs a A. Lack of exercise
vaginal exam and determines that the B. Hormonal disturbances
client’s cervix is 5cm dilated with 75% C. Lack of calcium
effacement. Based on the nurse’s D. Genetic predisposition
assessment the client is in which phase of 8. A 2-year-old is admitted for repair of a
labor? fractured femur and is placed in Bryant’s
traction. Which finding by the nurse
A. Active indicates that the traction is working
B. Latent
properly?
C. Transition
D. Early A. The infant no longer complains of pain.
3. A newborn with narcotic abstinence B. The buttocks are 15° off the bed.
syndrome is admitted to the nursery. C. The legs are suspended in the traction.
Nursing care of the newborn should D. The pins are secured within the pulley.
include: 9. A client with a fractured hip has been
placed in Buck’s traction. Which
A. Teaching the mother to provide tactile statement is true regarding balanced
stimulation
skeletal traction? Balanced skeletal
B. Wrapping the newborn snugly in a blanket
C. Placing the newborn in the infant seat traction:
D. Initiating an early infant-stimulation program
A. Utilizes a Steinman pin
4. A client elects to have epidural B. Requires that both legs be secured
anesthesia to relieve the discomfort of C. Utilizes Kirschner wires
labor. Following the initiation of epidural D. Is used primarily to heal the fractured hips
anesthesia, the nurse should give priority 10. The client is admitted for an open
to: reduction internal fixation of a fractured
hip. Immediately following surgery, the
A. Checking for cervical dilation
nurse should give priority to assessing
B. Placing the client in a supine position
C. Checking the client’s blood pressure the:
D. Obtaining a fetal heart rate A. Serum collection (Davol) drain
5. The nurse is aware that the best way to B. Client’s pain
prevent post- operative wound infection in C. Nutritional status
the surgical client is to: D. Immobilizer
11. Which statement made by the family
A. Administer a prescribed antibiotic
member caring for the client with a
B. Wash her hands for 2 minutes before care
C. Wear a mask when providing care percutaneous gastrostomy tube indicates
D. Ask the client to cover her mouth when she understanding of the nurse’s teaching?
coughs
A. “I must flush the tube with water after
6. The elderly client is admitted to the feedings and clamp the tube.”
emergency room. Which symptom is the B. “I must check placement four times per day.”
C. “I will report to the doctor any signs of
indigestion.”
D. “If my father is unable to swallow, I will
discontinue the feeding and call the clinic.”
12. The nurse is assessing the client with
a total knee replacement 2 hours post-
operative. Which information requires
notification of the doctor?
A. Bleeding on the dressing is 3cm in diameter.
B. The client has a temperature of 6°F.
C. The client’s hematocrit is 26%.
D. The urinary output has been 60 during the last
2 hours.
13. The nurse is caring for the client with
a 5-year-old diagnosis of plumbism.
Which information in the health history is
most likely related to the development of
plumbism?
A. The client has traveled out of the country in
the last 6 months.
B. The client’s parents are skilled stained-glass
artists.
C. The client lives in a house built in 1
D. The client has several brothers and sisters.
14. A client with a total hip replacement
requires special equipment. Which
equipment would assist the client with a
total hip replacement with activities of
daily living?
A. High-seat commode
B. Recliner
C. TENS unit
D. Abduction pillow
15. An elderly client with an abdominal
surgery is admitted to the unit following
surgery. In anticipation of complications of
anesthesia and narcotic administration,
the nurse should:
A. Administer oxygen via nasal cannula
B. Have narcan (naloxane) available
C. Prepare to administer blood products
D. Prepare to do cardioresuscitation
16. Which roommate would be most
suitable for the 6-year-old male with a
fractured femur in Russell’s traction?
A. 16-year-old female with scoliosis
B. 12-year-old male with a fractured femur
C. 10-year-old male with sarcoma
D. 6-year-old male with osteomylitis
17. A client with osteoarthritis has a
prescription for Celebrex (celecoxib).
Which instruction should be included in
the discharge teaching?
A. Take the medication with milk.
B. Report chest pain.
C. Remain upright after taking for 30 minutes.
D. Allow 6 weeks for optimal effects.
18. A client with a fractured tibia has a
plaster-of-Paris cast applied to immobilize
the fracture. Which action by the nurse
indicates understanding of a plaster-of-
Paris cast? The nurse:
A. Handles the cast with the fingertips
B. Petals the cast
C. Dries the cast with a hair dryer
D. Allows 24 hours before bearing weight
19. The teenager with a fiberglass cast
asks the nurse if it will be okay to allow
his friends to autograph his cast. Which
response would be best?
A. “It will be alright for your friends to
autograph the cast.”
B. “Because the cast is made of plaster,
autographing can weaken the cast.”
C. “If they don’t use chalk to autograph, it is
okay.”
D. “Autographing or writing on the cast in any
form will harm the cast.”
20. The nurse is assigned to care for the
client with a Steinmen pin. During pin
care, she notes that the LPN uses sterile
gloves and Q-tips to clean the pin. Which
action should the nurse take at this time?
A. Assisting the LPN with opening sterile
packages and peroxide
B. Telling the LPN that clean gloves are allowed
C. Telling the LPN that the registered nurse
should perform pin care
D. Asking the LPN to clean the weights and
pulleys with peroxide
21. A child with scoliosis has a spica cast
applied. Which action specific to the spica
cast should be taken?
A. Check the bowel sounds
B. Assess the blood pressure
C. Offer pain medication
D. Check for swelling
22. The client with a cervical fracture is
placed in traction. Which type of traction
will be utilized at the time of discharge?
A. Russell’s traction
B. Buck’s traction
C. Halo traction
D. Crutchfield tong traction
23. A client with a total knee replacement
has a CPM (continuous passive motion
device) applied during the post-operative
period. Which statement made by the
nurse indicates understanding of the CPM
machine?
A. “Use of the CPM will permit the client to
ambulate during the therapy.”
B. “The CPM machine controls should be
positioned distal to the site.”
C.  “If the client complains of pain during the
therapy, I will turn off the machine and call
the doctor.”
D. “Use of the CPM machine will alleviate the
need for physical therapy after the client is
discharged.”
24. A client with a fractured hip is being
taught correct use of the walker. The
nurse is aware that the correct use of the
walker is achieved if the:
A. Palms rest lightly on the handles
B. Elbows are flexed 0°
C. Client walks to the front of the walker
D. Client carries the walker
25. When assessing a laboring client, the
nurse finds a prolapsed cord. The nurse
should:
A. Attempt to replace the cord
B. Place the client on her left side
C. Elevate the client’s hips
D. Cover the cord with a dry, sterile gauze
26. A nurse is told in report that a client
has a positive Chvostek’s sign. What
other data would the nurse expect to find
on data collection? Select all that apply.
A. Coma
B. Tetany
C. Diarrhea
D. Possible seizure activity
E. Hypoactive bowel sounds
F. Positive Trousseau’s sign
27. A nurse lawyer provides an education
session to the nursing staff regarding
client rights. A nurse asks the lawyer to
describe an example that may relate to
invasion of client privacy. A nursing action
that indicates a violation of this right is:
A. Threatening to place a client in restraints
B. Performing a surgical procedure without
consent
C. Taking photographs of the client without
consent
D. Telling the client that he or she cannot leave
the hospital
28. A nurse notes in the medical record
that a client with Cushing’s syndrome is
experiencing fluid overload. Which
interventions should be included in the
plan of care? Select all that apply.
A. Monitoring daily weight
B. Monitoring intake and output
C. Maintaining a low-potassium diet
D. Monitoring extremities for edema
E. Maintaining a low-sodium diet
29. A nurse reinforces instructions to the
mother of a child who has been
hospitalized with croup. Which of the
following statements, if made by the
mother, would indicate the need for
further instruction?
A. “I will give my child cough syrup if a cough
develops.”
B. “During an attack, I will take my child to a
cool location.”
C.  “I will give acetaminophen (Tylenol) if my
child develops a fever.”
D. “I will be sure that my child drinks at least
three to four glasses of fluids every day.”
30. Which instruction should the nurse
provide to the client with diabetes mellitus
receiving acarbose (Precose)? Select all
that apply.
A. “Take the medication at bedtime.”
B. “Take the medication with each meal.”
C. “Take the medication on an empty stomach.”
D.  “Side effects include abdominal bloating and
flatus.”
E. “Take some form of glucose if hypoglycemia
occurs.”
F. “Report symptoms such as shortness of breath
or tiredness.”
 Answers and Rationales
1. Answer B is correct. When the membranes
rupture, there is often a transient drop in the
fetal heart tones. The heart tones should return
to baseline quickly. Any alteration in fetal
heart tones, such as bradycardia or
tachycardia, should be reported. After the fetal
heart tones are assessed, the nurse should
evaluate the cervical dilation, vital signs, and
level of discomfort, making answers A, C, and
D incorrect.
2. Answer A is correct. The active phase of
labor occurs when the client is dilated 4–7cm.
The latent or early phase of labor is from 1cm
to 3cm in dilation, so answers B and D are
incorrect. The transition phase of labor is 8–
10cm in dilation, making answer C incorrect.
3. Answer B is correct. The infant of an
addicted mother will undergo withdrawal.
Snugly wrapping the infant in a blanket will
help prevent the muscle irritability that these
babies often experience. Teaching the mother
to provide tactile stimulation or provide for
early infant stimulation are incorrect because
he is irritable and needs quiet and little
stimulation at this time, so answers A and D
are incorrect. Placing the infant in an infant
seat in answer C is incorrect because this will
also cause movement that can increase muscle
irritability.
4. Answer C is correct. Following epidural
anesthesia, the client should be checked for
hypotension and signs of shock every 5
minutes for 15 minutes. The client can be
checked for cervical dilation later after she is
stable. The client should not be positioned
supine because the anesthesia can move above
the respiratory center and the client can stop
breathing. Fetal heart tones should be assessed
after the blood pressure is checked. Therefore,
answers A, B, and D are incorrect.
5. Answer B is correct. The best way to prevent
post-operative wound infection is hand
washing. Use of prescribed antibiotics will
treat infection, not prevent infections, making
answer A incorrect. Wearing a mask and
asking the client to cover her mouth are good
practices but will not prevent wound
infections; therefore, answers C and D are
incorrect.
6. Answer B is correct. The client with a hip
fracture will most likely have disalignment.
Answers A, C, and D are incorrect because all
fractures cause pain, and coolness of the
extremities and absence of pulses are
indicative of compartment syndrome or
peripheral vascular disease.
7. Answer B is correct. After menopause,
women lack hormones necessary to absorb
and utilize calcium. Doing weight-bearing
exercises and taking calcium supplements can
help to prevent osteoporosis but are not
causes, so answers A and C are incorrect.
Body types that frequently experience
osteoporosis are thin Caucasian females, but
they are not most likely related to
osteoporosis, so answer D is incorrect.
8. Answer B is correct. The infant’s hips should
be off the bed approximately 15° in Bryant’s
traction. Answer A is incorrect because this
does not indicate that the traction is working
correctly, nor does C. Answer D is incorrect
because Bryant’s traction is a skin traction,
not a skeletal traction.
9. Answer A is correct. Balanced skeletal
traction uses pins and screws. A Steinman pin
goes through large bones and is used to
stabilize large bones such as the femur.
Answer B is incorrect because only the
affected leg is in traction. Kirschner wires are
used to stabilize small bones such as fingers
and toes, as in answer C. Answer D is
incorrect because this type of traction is not
used for fractured hips.
10.Answer A is correct. Bleeding is a common
complication of orthopedic surgery. The
blood-collection device should be checked
frequently to ensure that the client is not
hemorrhaging. The client’s pain should be
assessed, but this is not life-threatening. When
the client is in less danger, the nutritional
status should be assessed and an immobilizer
is not used; thus, answers B, C, and D are
incorrect.
11.Answer A is correct. The client’s family
member should be taught to flush the tube
after each feeding and clamp the tube. The
placement should be checked before feedings,
and indigestion can occur with the PEG tube,
just as it can occur with any client, so answers
B and C are incorrect. Medications can be
ordered for indigestion, but it is not a reason
for alarm. A percutaneous endoscopy
gastrostomy tube is used for clients who have
experienced difficulty swallowing. The tube is
inserted directly into the stomach and does not
require swallowing; therefore, answer D is
incorrect.
12.Answer C is correct. The client with a total
knee replacement should be assessed for
 anemia. A hematocrit of 26% is extremely
low and might require a blood transfusion.
Bleeding of 2cm on the dressing is not
extreme. Circle and date and time the bleeding
and monitor for changes in the client’s status.
A low-grade temperature is not unusual after
surgery. Ensure that the client is well
hydrated, and recheck the temperature in 1
hour. If the temperature is above 101°F, report
this finding to the doctor. Tylenol will
probably be ordered. Voiding after surgery is
also not uncommon and no need for concern;
therefore answers A, B, and D are incorrect.
13.Answer B is correct. Plumbism is lead
poisoning. One factor associated with the
consumption of lead is eating from pottery
made in Central America or Mexico that is
unfired. The child lives in a house built after
1976 (this is when lead was taken out of
paint), and the parents make stained glass as a
hobby. Stained glass is put together with lead,
which can drop on the work area, where the
child can consume the lead beads. Answer A
is incorrect because simply traveling out of
the country does not increase the risk. In
answer C, the house was built after the lead
was removed with the paint. Answer D is
unrelated to the stem.
14.Answer A is correct. The equipment that can
help with activities of daily living is the high-
seat commode. The hip should be kept higher
than the knee. The recliner is good because it
prevents 90° flexion but not daily activities. A
TENS (Transcutaneous Electrical Nerve
Stimulation) unit helps with pain management
and an abduction pillow is used to prevent
adduction of the hip and possibly dislocation
of the prosthesis; therefore, answers B, C, and
D are incorrect.
15.Answer B is correct. Narcan is the antidote
for narcotic overdose. If hypoxia occurs, the
client should have oxygen administered by
mask, not cannula. There is no data to support
the administration of blood products or
cardioresuscitation, so answers A, C, and D
are incorrect.
16.Answer B is correct. The 6-year-old should
have a roommate as close to the same age as
possible, so the 12-year-old is the best match.
The 10-year-old with sarcoma has cancer and
will be treated with chemotherapy that makes
him immune suppressed, the 6-year-old with
osteomylitis is infected, and the client in
answer A is too old and is female; therefore,
answers A, C, and D are incorrect.
17.Answer B is correct. Cox II inhibitors have
been associated with heart attacks and strokes.
Any changes in cardiac status or signs of a
stroke should be reported immediately, along
with any changes in bowel or bladder habits
because bleeding has been linked to use of
Cox II inhibitors. The client does not have to
take the medication with milk, remain upright,
or allow 6 weeks for optimal effect, so
answers A, C, and D are incorrect.
18.Answer D is correct. A plaster-of-Paris cast
takes 24 hours to dry, and the client should
not bear weight for 24 hours. The cast should
be handled with the palms, not the fingertips,
so answer A is incorrect. Petaling a cast is
covering the end of the cast with cast batting
or a sock, to prevent skin irritation and flaking
of the skin under the cast, making answer B
incorrect. The client should be told not to dry
the cast with a hair dryer because this causes
hot spots and could burn the client. This also
causes unequal drying; thus, answer C is
incorrect.
19.Answer A is correct. There is no reason that
the client’s friends should not be allowed to
autograph the cast; it will not harm the cast in
any way, so answers B, C, and D are
incorrect.
20.Answer A is correct. The nurse is performing
the pin care correctly when she uses sterile
gloves and Q-tips. A licensed practical nurse
can perform pin care, there is no need to clean
the weights, and the nurse can help with
opening the packages but it isn’t required;
therefore, answers B, C, and D are incorrect.
21.Answer A is correct. A body cast or spica
cast extends from the upper abdomen to the
knees or below. Bowel sounds should be
checked to ensure that the client is not
experiencing a paralytic illeus. Checking the
blood pressure is a treatment for any client,
offering pain medication is not called for, and
checking for swelling isn’t specific to the
stem, so answers B, C, and D are incorrect.
22.Answer C is correct. Halo traction will be
ordered for the client with a cervical fracture.
Russell’s traction is used for bones of the
lower extremities, as is Buck’s traction.
Cruchfield tongs are used while in the hospital
and the client is immobile; therefore, answers
A, B, and D are incorrect.
23.Answer B is correct. The controller for the
continuous passive-motion device should be
placed away from the client. Many clients
complain of pain while having treatments with
 the CPM, so they might turn off the machine. 29.Answer A is correct. Cough syrups and cold
The CPM flexes and extends the leg. The medicines are not to be given, because they
client is in the bed during CPM therapy, so may dry and thicken secretions. During a
answer A is incorrect. Answer C is incorrect croup attack, the child can be taken to a cool
because clients will experience pain with the basement or garage. Acetaminophen is used if
treatment. Use of the CPM does not alleviate a fever develops. Adequate hydration of 500
the need for physical therapy, as suggested in to 1000 mL of fluids daily is important for
answer D. thinning secretions.
24.Answer A is correct. The client’s palms 30.Answers: B, D, E, and F are correct. The
should rest lightly on the handles. The elbows mechanism of action of acarbose is a delay in
should be flexed no more than 30° but should absorption of dietary carbohydrates, thereby
not be extended. Answer B is incorrect reducing the rise in blood glucose after a
because 0° is not a relaxed angle for the meal. To accomplish this, the medication must
elbows and will not facilitate correct walker be taken with each meal. Because of its
use. The client should walk to the middle of bacterial fermentation of unabsorbed
the walker, not to the front of the walker, carbohydrates in the colon, side effects such
making answer C incorrect. The client should as borborygmus, cramps, abdominal
be taught not to carry the walker because this distention, and flatulence can occur. The
would not provide stability; thus, answer D is medication also can affect absorption of iron,
incorrect. leading to symptoms (shortness of breath,
25.Answer C is correct. The client with a tiredness) of anemia.
prolapsed cord should be treated by elevating
the hips and covering the cord with a moist,
sterile saline gauze. The nurse should use her
fingers to push up on the presenting part until
a cesarean section can be performed. Answers
A, B, and D are incorrect. The nurse should
not attempt to replace the cord, turn the client
on the side, or cover with a dry gauze.
26.Answers: B, C, D and F are correct. A
positive Chvostek’s sign is indicative of
hypocalcemia. Other signs and symptoms
include tachycardia, hypotension,
paresthesias, twitching, cramps, tetany,
seizures, positive Trousseau’s sign, diarrhea,
hyperactive bowel sounds, and a prolonged
QT interval.
27.Answer: C is correct. Invasion of privacy
takes place when an individual’s private
affairs are intruded on unreasonably.
Threatening to place a client in restraints
constitutes assault. Performing a surgical
procedure without consent is an example of
battery. Not allowing a client to leave the
hospital constitutes false imprisonment.
28.Answers: A, B, D, and E are correct. The
client with Cushing’s syndrome experiencing
fluid overload should be maintained on a
high-potassium and low-sodium diet.
Decreased sodium intake decreases renal
retention of sodium and water. Monitoring
weight, intake, output, and extremities for
edema are all appropriate interventions for
such a nursing diagnosis.
 NCLEX RN Practice Exam 13
1. The nurse is caring for a 30-year-old
male admitted with a stab wound. While
in the emergency room, a chest tube is A.
inserted. Which of the following explains B.
the primary rationale for insertion of chest C.
tubes? D.
A. The tube will allow for equalization of the
lung expansion.
B. Chest tubes serve as a method of draining
blood and serous fluid and assist in reinflating
the lungs.
A. Insulin requirements moderate as the
C. Chest tubes relieve pain associated with a
collapsed lung.
B. A decreased need for insulin occurs during the
D. Chest tubes assist with cardiac function by
stabilizing lung expansion.
C. Elevations in human chorionic gonadotrophin
2. A client who delivered this morning tells
the nurse that she plans to breastfeed her D. Fetal development depends on adequate
baby. The nurse is aware that successful
breastfeeding is most dependent on the:
A. Mother’s educational level
B. Infant’s birth weight
C. Size of the mother’s breast A.
D. Mother’s desire to breastfeed B.
3. The nurse is monitoring the progress of C.
a client in labor. Which finding should be D.
reported to the physician immediately?
A. The presence of scant bloody discharge
B. Frequent urination
C.  The presence of green-tinged amniotic fluid A.
D. Moderate uterine contractions B.
4. The nurse is measuring the duration of C.
the client’s contractions. Which statement D.
is true regarding the measurement of the
duration of contractions?
A. Duration is measured by timing from the
beginning of one contraction to the beginning
of the next contraction. A.
B. Duration is measured by timing from the end B.
of one contraction to the beginning of the next C.
contraction. D.
C. Duration is measured by timing from the
beginning of one contraction to the end of the
same contraction.
D. Duration is measured by timing from the peak
of one contraction to the end of the same
contraction.
5. The physician has ordered an
intravenous infusion of Pitocin for the
induction of labor. When caring for the
obstetric client receiving intravenous
Pitocin, the nurse should monitor for:
Maternal hypoglycemia
Fetal bradycardia
Maternal hyperreflexia
Fetal movement
6. A client with diabetes visits the prenatal
clinic at 28 weeks gestation. Which
statement is true regarding insulin needs
during pregnancy?
pregnancy progresses.
second trimester.
decrease the need for insulin.
insulin regulation.
7. A client in the prenatal clinic is
assessed to have a blood pressure of
180/96. The nurse should give priority to:
Providing a calm environment
Obtaining a diet history
Administering an analgesic
Assessing fetal heart tones
8. A primigravida, age 42, is 6 weeks
pregnant. Based on the client’s age, her
infant is at risk for:
Down syndrome
Respiratory distress syndrome
Turner’s syndrome
Pathological jaundice
9. A client with a missed abortion at 29
weeks gestation is admitted to the
hospital. The client will most likely be
treated with:
Magnesium sulfate
Calcium gluconate
Dinoprostone (Prostin E.)
Bromocrystine (Pardel)
10. A client with preeclampsia has been
receiving an infusion containing
magnesium sulfate for a blood pressure
that is 160/80; deep tendon reflexes are 1
plus, and the urinary output for the past
hour is 100mL. The nurse should:
A. Continue the infusion of magnesium sulfate
while monitoring the client’s blood pressure
B. Stop the infusion of magnesium sulfate and
contact the physician
C. Slow the infusion rate and turn the client on
her left side
D. Administer calcium gluconate IV push and
continue to monitor the blood pressure
11. Which statement made by the nurse
describes the inheritance pattern of
autosomal recessive disorders?
A. An affected newborn has unaffected parents.
B. An affected newborn has one affected parent.
C. Affected parents have a one in four chance of
passing on the defective gene.
D. Affected parents have unaffected children
who are carriers.
12. A pregnant client, age 32, asks the
nurse why her doctor has recommended
a serum alpha fetoprotein. The nurse
should explain that the doctor has
recommended the test:
A. Because it is a state law
B. To detect cardiovascular defects
C. Because of her age
D. To detect neurological defects
13. A client with hypothyroidism asks the
nurse if she will still need to take thyroid
medication during the pregnancy. The
nurse’s response is based on the
knowledge that:
A. There is no need to take thyroid medication
because the fetus’s thyroid produces a
thyroid-stimulating hormone.
B. Regulation of thyroid medication is more
difficult because the thyroid gland increases in
size during pregnancy.
C. It is more difficult to maintain thyroid
regulation during pregnancy due to a slowing
of metabolism.
D. Fetal growth is arrested if thyroid medication
is continued during pregnancy.
14. The nurse is responsible for
performing a neonatal assessment on a
full-term infant. At 1 minute, the nurse
could expect to find:
A. An apical pulse of 100
B. An absence of tonus
C. Cyanosis of the feet and hands
D. Jaundice of the skin and sclera
15. A client with sickle cell anemia is
admitted to the labor and delivery unit
during the first phase of labor. The nurse
should anticipate the client’s need for:
A. Supplemental oxygen
B. Fluid restriction
C. Blood transfusion
D. Delivery by Caesarean section
16. A client with diabetes has an order for
ultrasonography. Preparation for an
ultrasound includes:
A. Increasing fluid intake
B. Limiting ambulation
C. Administering an enema
D. Withholding food for 8 hours
17. An infant who weighs 8 pounds at
birth would be expected to weigh how
many pounds at 1 year?
A. 14 pounds
B. 16 pounds
C. 18 pounds
D. 24 pounds
18. A pregnant client with a history of
alcohol addiction is scheduled for a
nonstress test. The nonstress test:
A. Determines the lung maturity of the fetus
B. Measures the activity of the fetus
C. Shows the effect of contractions on the fetal
heart rate
D. Measures the neurological well-being of the
fetus
19. A full-term male has hypospadias.
Which statement describes hypospadias?
A. The urethral opening is absent.
B. The urethra opens on the dorsal side of the
penis.
C. The penis is shorter than usual.
D. The urethra opens on the ventral side of the
penis.
20. A gravida III para II is admitted to the
labor unit. Vaginal exam reveals that the
client’s cervix is 8cm dilated, with
complete effacement. The priority nursing
diagnosis at this time is:
A. Alteration in coping related to pain
B. Potential for injury related to precipitate
delivery
C. Alteration in elimination related to anesthesia 26. A nurse prepares a list of home care
D. Potential for fluid volume deficit related to instructions for the parents of a child who
NPO status
has a plaster cast applied to the left
21. The client with varicella will most likely
forearm. Choose the instructions that
have an order for which category of
would be included on the list. Select all
medication?
that apply.
A. Antibiotics A. Use the fingertips to lift the cast while it is
B. Antipyretics drying.
C. Antivirals B. Keep small toys and sharp objects away from
D. Anticoagulants the cast.
22. A client is admitted complaining of C. Use a padded ruler or another padded object
to scratch the skin under the cast if it itches.
chest pain. Which of the following drug D. Place a heating pad on the lower end of the
orders should the nurse question? cast and over the fingers if the fingers feel
cold.
A. Nitroglycerin
E. Contact the health care provider if the child
B. Ampicillin
complains of numbness or tingling in the
C. Propranolol
extremity.
D. Verapamil
F. Elevate the extremity on pillows for the first
23. Which of the following instructions 24 to 48 hours after casting to prevent
should be included in the teaching for the swelling.
client with rheumatoid arthritis? 27. The nurse would anticipate the use of
A.  Avoid exercise because it fatigues the joints. which medications in the treatment of the
B.  Take prescribed anti-inflammatory client with heart failure? Select all that
medications with meals. apply.
C.  Alternate hot and cold packs to affected A. Diuretics
joints. B. Anticoagulants
D.  Avoid weight-bearing activity. C. Anticholinergics
24. A client with acute pancreatitis is D. Cardiac glycosides
experiencing severe abdominal pain. E. Phosphodiesterase (PDE) inhibitors
F. Angiotensin-converting enzyme (ACE)
Which of the following orders should be
inhibitors
questioned by the nurse?
28. Which of these clients are most likely
A. Meperidine 100mg IM q 4 hours PRN pain to develop fluid (circulatory)
B. Mylanta 30 ccs q 4 hours via NG overload? Select all that apply.
C. Cimetadine 300mg PO q.i.d. A. A premature infant
D. Morphine 8mg IM q 4 hours PRN pain B. A 101-year-old man
25. The client is admitted to the chemical C. A client on renal dialysis
dependence unit with an order for D.  A client with diabetes mellitus
continuous observation. The nurse is E. A 29-year-old woman with pneumonia
F. A client with congestive heart failure
aware that the doctor has ordered
29. When the nurse is collecting data
continuous observation because:
from the older adult, which of the
A. Hallucinogenic drugs create both stimulant following findings would be considered
and depressant effects. normal physiological changes? Select all
B. Hallucinogenic drugs induce a state of altered that apply.
perception. A. Increased heart rate
C. Hallucinogenic drugs produce severe B. Decline in visual acuity
respiratory depression. C. Decreased respiratory rate
D. Hallucinogenic drugs induce rapid physical D. Decline in long-term memory
dependence E. Increased susceptibility to urinary tract
infections
F. Increased incidence of awakening after sleep
onset
30. Which data indicates to the nurse that
a client may be experiencing ineffective
coping?
A. Constantly neglects personal grooming
B. Visits her husband’s grave once a month
C. Visits the senior citizens’ center once a month
D. Frequently looks at snapshots of her husband
and family
Answers and Rationales
1. Answer B is correct. Chest tubes work to
reinflate the lung and drain serous fluid. The
tube does not equalize expansion of the lungs.
Pain is associated with collapse of the lung,
and insertion of chest tubes is painful, so
answers A and C are incorrect. Answer D is
true, but this is not the primary rationale for
performing chest tube insertion.
2. Answer D is correct. Success with
breastfeeding depends on many factors, but
the most dependable reason for success is
desire and willingness to continue the
breastfeeding until the infant and mother have
time to adapt. The educational level, the
infant’s birth weight, and the size of the
mother’s breast have nothing to do with
success, so answers A, B, and C are incorrect.
3. Answer C is correct. Green-tinged amniotic
fluid is indicative of meconium staining. This
finding indicates fetal distress. The presence
of scant bloody discharge is normal, as are
frequent urination and moderate uterine
contractions, making answers A, B, and D
incorrect.
4. Answer C is correct. Duration is measured
from the beginning of one contraction to the
end of the same contraction. Answer A refers
to frequency. Answer B is incorrect because
we do not measure from the end of one
contraction to the beginning of the next
contraction. Duration is not measured from
the peak of the contraction to the end, as
stated in D.
5. Answer B is correct. The client receiving
Pitocin should be monitored for decelerations.
There is no association with Pitocin use and
hypoglycemia, maternal hyperreflexia, or fetal
movement; therefore, answers A, C, and D are
incorrect.
6. Answer D is correct. Fetal development
depends on adequate nutrition and insulin
regulation. Insulin needs increase during the
second and third trimesters, insulin
requirements do not moderate as the
pregnancy progresses, and elevated human
chorionic gonadotrophin elevates insulin
needs, not decreases them; therefore, answers
A, B, and C are incorrect.
7. Answer A is correct. A calm environment is
needed to prevent seizure activity. Any
stimulation can precipitate seizures. Obtaining
a diet history should be done later, and
administering an analgesic is not indicated
because there is no data in the stem to indicate
pain. Therefore, answers B and C are
incorrect. Assessing the fetal heart tones is
important, but this is not the highest priority
in this situation as stated in answer D.
8. Answer A is correct. The client who is age
42 is at risk for fetal anomalies such as Down
syndrome and other chromosomal aberrations.
Answers B, C, and D are incorrect because the
client is not at higher risk for respiratory
distress syndrome or pathological jaundice,
and Turner’s syndrome is a genetic disorder.
9. Answer C is correct. The client with a
missed abortion will have induction of labor.
Prostin E. is a form of prostaglandin used to
soften the cervix. Magnesium sulfate is used
for preterm labor and preeclampsia, calcium
gluconate is the antidote for magnesium
sulfate, and Pardel is a dopamine receptor
stimulant used to treat Parkinson’s disease;
therefore, answers A, B, and D are incorrect.
Pardel was used at one time to dry breast
milk.
10.Answer A is correct. The client’s blood
pressure and urinary output are within normal
limits. The only alteration from normal is the
decreased deep tendon reflexes. The nurse
should continue to monitor the blood pressure
and check the magnesium level. The
therapeutic level is 4.8–9.6mg/dL. Answers B,
C, and D are incorrect. There is no need to
stop the infusion at this time or slow the rate.
Calcium gluconate is the antidote for
magnesium sulfate, but there is no data to
indicate toxicity.
11.Answer C is correct. Autosomal recessive
disorders can be passed from the parents to
the infant. If both parents pass the trait, the
child will get two abnormal genes and the
disease results. Parents can also pass the trait
to the infant. Answer A is incorrect because,
to have an affected newborn, the parents must
be carriers. Answer B is incorrect because
both parents must be carriers. Answer D is
 incorrect because the parents might have
affected children.
12.Answer D is correct. Alpha fetoprotein is a
screening test done to detect neural tube
defects such as spina bifida. The test is not
mandatory, as stated in answer A. It does not
indicate cardiovascular defects, and the
mother’s age has no bearing on the need for
the test, so answers B and C are incorrect.
13.Answer B is correct. During pregnancy, the
thyroid gland triples in size. This makes it
more difficult to regulate thyroid medication.
Answer A is incorrect because there could be
a need for thyroid medication during
pregnancy. Answer C is incorrect because the
thyroid function does not slow. Fetal growth
is not arrested if thyroid medication is
continued, so answer D is incorrect.
14.Answer C is correct. Cyanosis of the feet and
hands is acrocyanosis. This is a normal
finding 1 minute after birth. An apical pulse
should be 120–160, and the baby should have
muscle tone, making answers A and B
incorrect. Jaundice immediately after birth is
pathological jaundice and is abnormal, so
answer D is incorrect.
15. Answer A is correct. Clients with sickle cell
crises are treated with heat, hydration,
oxygen, and pain relief. Fluids are increased,
not decreased. Blood transfusions are usually
not required, and the client can be delivered
vaginally; thus, answers B, C, and D are
incorrect.
16.Answer A is correct. Before
ultrasonography, the client should be taught to
drink plenty of fluids and not void. The client
may ambulate, an enema is not needed, and
there is no need to withhold food for 8 hours.
Therefore, answers B, C, and D are incorrect.
17.Answer D is correct. By 1 year of age, the
infant is expected to triple his birth weight.
Answers A, B, and C are incorrect because
they are too low.
18.Answer B is correct. A nonstress test is done
to evaluate periodic movement of the fetus. It
is not done to evaluate lung maturity as in
answer A. An oxytocin challenge test shows
the effect of contractions on fetal heart rate
and a nonstress test does not measure
neurological well-being of the fetus, so
answers C and D are incorrect.
19. Answer B is correct. Hypospadia is a
condition in which there is an opening on the
dorsal side of the penis. Answer A is incorrect
because hypospadia does not concern the
urethral opening. Answer C is incorrect
because the size of the penis is not affected.
Answer D is incorrect because the opening is
on the dorsal side, not the ventral side.
20.Answer A is correct. Transition is the time
during labor when the client loses
concentration due to intense contractions.
Potential for injury related to precipitate
delivery has nothing to do with the dilation of
the cervix, so answer B is incorrect. There is
no data to indicate that the client has had
anesthesia or fluid volume deficit, making
answers C and D incorrect.
21.Answer C is correct. Varicella is chicken
pox. This herpes virus is treated with antiviral
medications. The client is not treated with
antibiotics or anticoagulants as stated in
answers A and D. The client might have a
fever before the rash appears, but when the
rash appears, the temperature is usually gone,
so answer B is incorrect.
22.Answer B is correct. Clients with chest pain
can be treated with nitroglycerin, a beta
blocker such as propanolol, or Varapamil.
There is no indication for an antibiotic such as
Ampicillin, so answers A, C, and D are
incorrect.
23.Answer B is correct. Anti-inflammatory
drugs should be taken with meals to avoid
stomach upset. Answers A, C, and D are
incorrect. Clients with rheumatoid arthritis
should exercise, but not to the point of pain.
Alternating hot and cold is not necessary,
especially because warm, moist soaks are
more useful in decreasing pain. Weight-
bearing activities such as walking are useful
but is not the best answer for the stem.
24.Answer D is correct. Morphine is
contraindicated in clients with gallbladder
disease and pancreatitis because morphine
causes spasms of the Sphenter of Oddi.
Meperidine, Mylanta, and Cimetadine are
ordered for pancreatitis, making answers A,
B, and C incorrect.
25.Answer B is correct. Hallucinogenic drugs
can cause hallucinations. Continuous
observation is ordered to prevent the client
from harming himself during withdrawal.
Answers A, C, and D are incorrect because
hallucinogenic drugs don’t create both
stimulant and depressant effects or produce
severe respiratory depression. However, they
do produce psychological dependence rather
than physical dependence.
26.Answers B, E, and F are correct. While the
cast is drying, the palms of the hands are used
to lift the cast. If the fingertips are used,
indentations in the cast could occur and cause
constant pressure on the underlying skin.
Small toys and sharp objects are kept away
from the cast, and no objects (including
padded objects) are placed inside of the cast
because of the risk of altered skin integrity. A
heating pad is not applied to the cast or
fingers. Cold fingers could indicate
neurovascular impairment, and the HCP
should be notified. The extremity is elevated
to prevent swelling, and the HCP is notified
immediately if any signs of neurovascular
impairment develop.
27.Answers A, D, E, and F are
correct. Medications recommended for
treatment of heart failure include diuretics,
cardiac glycosides such as digoxin (Lanoxin),
PDE inhibitors, and ACE inhibitors. Clients in
heart failure do not need anticoagulants or
anticholinergics.
28.Answers A, B, C, and F are correct. Clients
with cardiac, respiratory, renal, or liver
diseases and older and very young clients
cannot tolerate an excessive fluid volume. The
risk of fluid (circulatory) overload exists with
these clients
29.Answers B, E, and F are
correct. Anatomical changes to the eye affect
the individual’s visual ability, which leads to
potential problems with activities of daily
living. Light adaptation and visual fields are
reduced. Respiratory rates are usually
unchanged. The heart rate decreases, and the
heart valves thicken. Age-related changes that
affect the urinary tract increase an older
client’s susceptibility to urinary tract
infections. Short-term memory may decline
with age, but long-term memory is usually
maintained. Changes in sleep patterns are
consistent, age-related changes. Older persons
experience an increased incidence of
awakening after sleep onset.
30.Answer A is correct. Coping mechanisms are
behaviors that are used to decreased stress and
anxiety. In response to a death, ineffective
coping is manifested by an extreme behavior
that in some instances may be harmful to the
individual, physically, psychologically, or
both. Option 1 is indicative of a behavior that
identifies an ineffective coping behavior as
part of the grieving process. The remaining
options identify effective coping behaviors.
 NCLEX RN Practice Exam 14
1. A client with a history of abusing
barbiturates abruptly stops taking the
medication. The nurse should give priority
to assessing the client for:
A. Depression and suicidal ideation
B. Tachycardia and diarrhea
C. Muscle cramping and abdominal pain
D. Tachycardia and euphoric mood
2. During the assessment of a laboring
client, the nurse notes that the FHT are
loudest in the upper-right quadrant. The
infant is most likely in which position?
A. Right breech presentation
B. Right occipital anterior presentation
C. Left sacral anterior presentation
D.  Left occipital transverse presentation
3. The primary physiological alteration in
the development of asthma is:
A. Bronchiolar inflammation and dyspnea
B. Hypersecretion of abnormally viscous mucus
C. Infectious processes causing mucosal edema
D. Spasm of bronchiolar smooth muscle
4. A client with mania is unable to finish
her dinner. To help her maintain sufficient
nourishment, the nurse should:
A. Serve high-calorie foods she can carry with
her
B. Encourage her appetite by sending out for her
favorite foods
C. Serve her small, attractively arranged portions
D. Allow her in the unit kitchen for extra food
whenever she pleases
5. To maintain Bryant’s traction, the nurse
must make certain that the child’s:
A. Hips are resting on the bed, with the legs
suspended at a right angle to the bed
B. Hips are slightly elevated above the bed and
the legs are suspended at a right angle to the
bed
C. Hips are elevated above the level of the body
on a pillow and the legs are suspended parallel
to the bed
D. Hips and legs are flat on the bed, with the
traction positioned at the foot of the bed
6. Which action by the nurse indicates
understanding of herpes zoster?
A. The nurse covers the lesions with a sterile
dressing.
B. The nurse wears gloves when providing care.
C. The nurse administers a prescribed antibiotic.
D. The nurse administers oxygen.
7. The client has an order for a trough to
be drawn on the client receiving
Vancomycin. The nurse is aware that the
nurse should contact the lab for them to
collect the blood:
A. 15 minutes after the infusion
B. 30 minutes before the infusion
C. 1 hour after the infusion
D. 2 hours after the infusion
8. The client using a diaphragm should be
instructed to:
A. Refrain from keeping the diaphragm in longer
than 4 hours
B. Keep the diaphragm in a cool location
C. Have the diaphragm resized if she gains 5
pounds
D. Have the diaphragm resized if she has any
surgery
9. The nurse is providing postpartum
teaching for a mother planning to
breastfeed her infant. Which of the client’s
statements indicates the need for
additional teaching?
A. “I’m wearing a support bra.”
B. “I’m expressing milk from my breast.”
C.  “I’m drinking four glasses of fluid during a
24-hour period.”
D. “While I’m in the shower, I’ll allow the water
to run over my breasts.”
10. Damage to the VII cranial nerve
results in:
A. Facial pain
B. Absence of ability to smell
C. Absence of eye movement
D. Tinnitus
11. A client is receiving Pyridium
(phenazopyridine hydrochloride) for a
urinary tract infection. The client should
be taught that the medication may:
A. Cause diarrhea
B. Change the color of her urine
C. Cause mental confusion
D. Cause changes in taste
12. Which of the following tests should be
performed before beginning a prescription
of Accutane?
A. Check the calcium level B. The lens orchestrates eye movement.
B. Perform a pregnancy test C. The lens focuses light rays on the retina.
C. Monitor apical pulse D. The lens magnifies small objects.
D. Obtain a creatinine level 19. A client who has glaucoma is to have
13. A client with AIDS is taking Zovirax miotic eyedrops instilled in both eyes. The
(acyclovir). Which nursing intervention is nurse knows that the purpose of the
most critical during the administration of medication is to:
acyclovir?
A. Anesthetize the cornea
A. Limit the client’s activity B. Dilate the pupils
B. Encourage a high-carbohydrate diet C. Constrict the pupils
C. Utilize an incentive spirometer to improve D. Paralyze the muscles of accommodation
respiratory function 20. A client with a severe corneal ulcer
D. Encourage fluids has an order for Gentamycin gtt. q 4
14. A client is admitted for an MRI. The hours and Neomycin 1 gtt q 4 hours.
nurse should question the client Which of the following schedules should
regarding: be used when administering the drops?
A. Pregnancy A. Allow 5 minutes between the two
B. A titanium hip replacement medications.
C. Allergies to antibiotics B. The medications may be used together.
D. Inability to move his feet C. The medications should be separated by a
15. The nurse is caring for the client cycloplegic drug.
receiving Amphotericin B. Which of the D. The medications should not be used in the
following indicates that the client has same client.
experienced toxicity to this drug? 21. The client with color blindness will
most likely have problems distinguishing
A. Changes in vision
which of the following colors?
B. Nausea
C. Urinary frequency A. Orange
D. Changes in skin color B. Violet
16. The nurse should visit which of the C. Red
following clients first? D. White
22. The client with a pacemaker should
A. The client with diabetes with a blood glucose
be taught to:
of 95mg/dL
B. The client with hypertension being maintained A. Report ankle edema
on Lisinopril B. Check his blood pressure daily
C.  The client with chest pain and a history of C. Refrain from using a microwave oven
angina D. Monitor his pulse rate
D.  The client with Raynaud’s disease 23. The client with enuresis is being
17. A client with cystic fibrosis is taking taught regarding bladder retraining. The
pancreatic enzymes. The nurse should nurse should advise the client to refrain
administer this medication: from drinking after:
A. Once per day in the morning A. 1900
B. Three times per day with meals B. 1200
C. Once per day at bedtime C. 1000
D. Four times per day D. 0700
18. Cataracts result in opacity of the 24. Which of the following diet instructions
crystalline lens. Which of the following should be given to the client with
best explains the functions of the lens? recurring urinary tract infections?
A. The lens controls stimulation of the retina.
A. Increase intake of meats.
B. Avoid citrus fruits.
C. Perform pericare with hydrogen peroxide.
D. Drink a glass of cranberry juice every day.
25. The physician has prescribed NPH
insulin for a client with diabetes mellitus.
Which statement indicates that the client
knows when the peak action of the insulin
occurs?
A. “I will make sure I eat breakfast within 2
hours of taking my insulin.”
B. “I will need to carry candy or some form of
sugar with me all the time.”
C. “I will eat a snack around three o’clock each
afternoon.”
D. “I can save my dessert from supper for a
bedtime snack.”
Answers and Rationales
1. Answer B is correct. Barbiturates create a
sedative effect. When the client stops taking
barbiturates, he will experience tachycardia,
diarrhea, and tachpnea. Answer A is incorrect
even though depression and suicidal ideation
go along with barbiturate use; it is not the
priority. Muscle cramps and abdominal pain
are vague symptoms that could be associated
with other problems. Tachycardia is
associated with stopping barbiturates, but
euphoria is not.
2. Answer A is correct. If the fetal heart tones
are heard in the right upper abdomen, the
infant is in a breech presentation. If the infant
is positioned in the right occipital anterior
presentation, the FHTs will be located in the
right lower quadrant, so answer B is incorrect.
If the fetus is in the sacral position, the FHTs
will be located in the center of the abdomen,
so answer C is incorrect. If the FHTs are
heard in the left lower abdomen, the infant is
most likely in the left occipital transverse
position, making answer D incorrect.
3. Answer D is correct. Asthma is the presence
of bronchiolar spasms. This spasm can be
brought on by allergies or anxiety. Answer A
is incorrect because the primary physiological
alteration is not inflammation. Answer B is
incorrect because there is the production of
abnormally viscous mucus, not a primary
alteration. Answer C is incorrect because
infection is not primary to asthma.
4. Answer A is correct. The client with mania is
seldom sitting long enough to eat and burns
many calories for energy. Answer B is
incorrect because the client should be treated
the same as other clients. Small meals are not
a correct option for this client. Allowing her
into the kitchen gives her privileges that other
clients do not have and should not be allowed,
so answer D is incorrect.
5. Answer B is correct. Bryant’s traction is used
for fractured femurs and dislocated hips. The
hips should be elevated 15° off the bed.
Answer A is incorrect because the hips should
not be resting on the bed. Answer C is
incorrect because the hips should not be above
the level of the body. Answer D is incorrect
because the hips and legs should not be flat on
the bed.
6. Answer B is correct. Herpes zoster is
shingles. Clients with shingles should be
placed in contact precautions. Wearing gloves
during care will prevent transmission of the
virus. Covering the lesions with a sterile
gauze is not necessary, antibiotics are not
prescribed for herpes zoster, and oxygen is not
necessary for shingles; therefore, answers A,
C, and D are incorrect.
7. Answer B is correct. A trough level should
be drawn 30 minutes before the third or fourth
dose. The times in answers A, C, and D are
incorrect times to draw blood levels.
8. Answer B is correct. The client using a
diaphragm should keep the diaphragm in a
cool location. Answers A, C, and D are
incorrect. She should refrain from leaving the
diaphragm in longer than 8 hours, not 4 hours.
She should have the diaphragm resized when
she gains or loses 10 pounds or has abdominal
surgery.
9. Answer C is correct. Mothers who plan to
breastfeed should drink plenty of liquids, and
four glasses is not enough in a 24-hour period.
Wearing a support bra is a good practice for
the mother who is breastfeeding as well as the
mother who plans to bottle-feed, so answer A
is incorrect. Expressing milk from the breast
will stimulate milk production, making
answer B incorrect. Allowing the water to run
over the breast will also facilitate “letdown,”
when the milk begins to be produced; thus,
answer D is incorrect.
10.Answer A is correct. The facial nerve is
cranial nerve VII. If damage occurs, the client
will experience facial pain. The auditory
nerve is responsible for hearing loss and
tinnitus, eye movement is controlled by the
Trochear or C IV, and the olfactory nerve
 controls smell; therefore, answers B, C, and D
are incorrect.
11.Answer B is correct. Clients taking Pyridium
should be taught that the medication will turn
the urine orange or red. It is not associated
with diarrhea, mental confusion, or changes in
taste; therefore, answers A, C, and D are
incorrect. Pyridium can also cause a yellowish
color to skin and sclera if taken in large doses.
12.Answer B is correct. Accutane is
contraindicated for use by pregnant clients
because it causes teratogenic effects. Calcium
levels, apical pulse, and creatinine levels are
not necessary; therefore, answers A, C, and D
are incorrect.
13.Answer D is correct. Clients taking
Acyclovir should be encouraged to drink
plenty of fluids because renal impairment can
occur. Limiting activity is not necessary, nor
is eating a high-carbohydrate diet. Use of an
incentive spirometer is not specific to clients
taking Acyclovir; therefore, answers A, B,
and C are incorrect.
14.Answer A is correct. Clients who are
pregnant should not have an MRI because
radioactive isotopes are used. However,
clients with a titanium hip replacement can
have an MRI, so answer B is incorrect. No
antibiotics are used with this test and the
client should remain still only when
instructed, so answers C and D are not
specific to this test.
15.Answer D is correct. Clients taking
Amphotericin B should be monitored for
liver, renal, and bone marrow function
because this drug is toxic to the kidneys and
liver, and causes bone marrow suppression.
Jaundice is a sign of liver toxicity and is not
specific to the use of Amphotericin B.
Changes in vision are not related, and nausea
is a side effect, not a sign of toxicity; nor is
urinary frequency. Thus, answers A, B, and C
are incorrect.
16.Answer C is correct. The client with chest
pain should be seen first because this could
indicate a myocardial infarction. The client in
answer A has a blood glucose within normal
limits. The client in answer B is maintained
on blood pressure medication. The client in
answer D is in no distress.
17.Answer B is correct. Pancreatic enzymes
should be given with meals for optimal
effects. These enzymes assist the body in
digesting needed nutrients. Answers A, C, and
D are incorrect methods of administering
pancreatic enzymes.
18.Answer C is correct. The lens allows light to
pass through the pupil and focus light on the
retina. The lens does not stimulate the retina,
assist with eye movement, or magnify small
objects, so answers A, B, and D are incorrect.
19.Answer C is correct. Miotic eyedrops
constrict the pupil and allow aqueous humor
to drain out of the Canal of Schlemm. They do
not anesthetize the cornea, dilate the pupil, or
paralyze the muscles of the eye, making
answers A, B, and D incorrect.
20.Answer A is correct. When using eyedrops,
allow 5 minutes between the two medications;
therefore, answer B is incorrect. These
medications can be used by the same client
but it is not necessary to use a cyclopegic with
these medications, making answers C and D
incorrect.
21.Answer B is correct. Clients with color
blindness will most likely have problems
distinguishing violets, blues, and green. The
colors in answers A, C, and D are less
commonly affected.
22.Answer D is correct. The client with a
pacemaker should be taught to count and
record his pulse rate. Answers A, B, and C are
incorrect. Ankle edema is a sign of right-sided
congestive heart failure. Although this is not
normal, it is often present in clients with heart
disease. If the edema is present in the hands
and face, it should be reported. Checking the
blood pressure daily is not necessary for these
clients. The client with a pacemaker can use a
microwave oven, but he should stand about 5
feet from the oven while it is operating.
23.Answer A is correct. Clients who are being
retrained for bladder control should be taught
to withhold fluids after about 7 p.m., or 1 The
times in answers B, C, and D are too early in
the day.
24.Answer D is correct. Cranberry juice is more
alkaline and, when metabolized by the body,
is excreted with acidic urine. Bacteria does
not grow freely in acidic urine. Increasing
intake of meats is not associated with urinary
tract infections, so answer A is incorrect. The
client does not have to avoid citrus fruits and
pericare should be done, but hydrogen
peroxide is drying, so answers B and C are
incorrect.
25.Answer C is correct. NPH insulin peaks in
8–12 hours, so a snack should be offered at
that time. NPH insulin onsets in 90–120
minutes, so answer A is incorrect. Answer B
is untrue because NPH insulin is time released
and does not usually cause sudden
hypoglycemia. Answer D is incorrect, but the
client should eat a bedtime snack.
 NCLEX RN Practice Exam 15
1. Which individual is at greatest risk for
developing hypertension?
A. 45 year-old African American attorney
B. 60 year-old Asian American shop owner
C. 40 year-old Caucasian nurse
D. 55 year-old Hispanic teacher
2. A child who ingested 15 maximum
strength acetaminophen tablets 45
minutes ago is seen in the emergency
department. Which of these orders should
the nurse do first?
A. Gastric lavage PRN
B. Acetylcysteine (mucomyst) for age per
pharmacy
C. Start an IV Dextrose 5% with 0.33% normal
saline to keep vein open
D. Activated charcoal per pharmacy
3. Which complication of cardiac
catheterization should the nurse monitor
for in the initial 24 hours after the
procedure?
A. angina at rest
B. thrombus formation
C. dizziness
D. falling blood pressure
4. A client is admitted to the emergency
room with renal calculi and is complaining
of moderate to severe flank pain and
nausea. The client’s temperature is 100.8
degrees Fahrenheit. The priority nursing
goal for this client is
A. Maintain fluid and electrolyte balance
B. Control nausea
C. Manage pain
D. Prevent urinary tract infection
5. What would the nurse expect to see
while assessing the growth of children
during their school age years?
A. Decreasing amounts of body fat and muscle
mass
B. Little change in body appearance from year to
year
C. Progressive height increase of 4 inches each
year
D.  Yearly weight gain of about 5.5 pounds per
year
6. At a community health fair the blood
pressure of a 62 year-old client is 160/96.
The client states “My blood pressure is
usually much lower.” The nurse should
tell the client to
A. go get a blood pressure check within the next
48 to 72 hours
B. check blood pressure again in 2 months
C. see the health care provider immediately
D. visit the health care provider within 1 week
for a BP check
7. The hospital has sounded the call for a
disaster drill on the evening shift. Which
of these clients would the nurse put first
on the list to be discharged in order to
make a room available for a new
admission?
A. A middle aged client with a history of being
ventilator dependent for over 7 years and
admitted with bacterial pneumonia five days
ago
B. A young adult with diabetes mellitus Type 2
for over 10 years and admitted with antibiotic
induced diarrhea 24 hours ago
C. An elderly client with a history of
hypertension, hypercholesterolemia and lupus,
and was admitted with Stevens-Johnson
syndrome that morning
D. An adolescent with a positive HIV test and
admitted for acute cellulitus of the lower leg
48 hours ago
8. A client has been newly diagnosed with
hypothyroidism and will take
levothyroxine (Synthroid) 50 mcg/day by
mouth. As part of the teaching plan, the
nurse emphasizes that this medication:
A. Should be taken in the morning
B. May decrease the client’s energy level
C. Must be stored in a dark container
D. Will decrease the client’s heart rate
9. A 3 year-old child comes to the
pediatric clinic after the sudden onset of
findings that include irritability, thick
muffled voice, croaking on inspiration, hot
to touch, sit leaning forward, tongue
protruding, drooling and suprasternal
retractions. What should the nurse do
first?
A. Prepare the child for x-ray of upper airways 14. Which of these findings indicate that a
B. Examine the child’s throat pump to deliver a basal rate of 10 ml per
C. Collect a sputum specimen
hour plus PRN for pain break through for
D. Notify the healthcare provider of the child’s
status morphine drip is not working?
10. In children suspected to have a A. The client complains of discomfort at the IV
diagnosis of diabetes, which one of the insertion site
following complaints would be most likely B. The client states “I just can’t get relief from
to prompt parents to take their school age my pain.”
C. The level of drug is 100 ml at 8 AM and is 80
child for evaluation?
ml at noon
A. Polyphagia D. The level of the drug is 100 ml at 8 AM and is
B. Dehydration 50 ml at noon
C. Bed wetting 15. The nurse is speaking at a community
D. Weight loss meeting about personal responsibility for
11. A client comes to the clinic for health promotion. A participant asks
treatment of recurrent pelvic inflammatory about chiropractic treatment for illnesses.
disease. The nurse recognizes that this What should be the focus of the nurse’s
condition most frequently follows which response?
type of infection?
A.  Electrical energy fields
A. Trichomoniasis B. Spinal column manipulation
B. Chlamydia C. Mind-body balance
C. Staphylococcus D. Exercise of joints
D. Streptococcus 16. The nurse is performing a
12. An RN who usually works in a spinal neurological assessment on a client post
rehabilitation unit is floated to the right CVA. Which finding, if observed by
emergency department. Which of these the nurse, would warrant immediate
clients should the charge nurse assign to attention?
this RN?
A. Decrease in level of consciousness
A. A middle-aged client who says “I took too B. Loss of bladder control
many diet pills” and “my heart feels like it is C. Altered sensation to stimuli
racing out of my chest.” D. Emotional ability
B. A young adult who says “I hear songs from 17. A child who has recently been
heaven. I need money for beer. I quit drinking diagnosed with cystic fibrosis is in a
2 days ago for my family. Why are my arms
pediatric clinic where a nurse is
and legs jerking?”
C. An adolescent who has been on pain performing an assessment. Which later
medications terminal cancer with an initial finding of this disease would the nurse not
assessment finding pupils and a relaxed expect to see at this time?
respiratory rate of 10
D. An elderly client who reports having taken a A. Positive sweat test
“large crack hit” 10 minutes prior to walking B. Bulky greasy stools
into the emergency room C. Moist, productive cough
D. Meconium ileus
13. When teaching a client with coronary
18. The home health nurse visits a male
artery disease about nutrition, the nurse
client to provide wound care and finds the
should emphasize
client lethargic and confused. His wife
A. Eating 3 balanced meals a day states he fell down the stairs 2 hours ago.
B. Adding complex carbohydrates The nurse should
C. Avoiding very heavy meals
D. Limiting sodium to 7 gms per day
A. Place a call to the client’s health care provider
for instructions
B. Send him to the emergency room for
evaluation
C. Reassure the client’s wife that the symptoms
are transient
D. Instruct the client’s wife to call the doctor if
his symptoms become worse
19. Which of the following should the
nurse implement to prepare a client for a
KUB (Kidney, Ureter, Bladder) radiograph
test?
A. Client must be NPO before the examination
B. Enema to be administered prior to the
examination
C. Medicate client with Lasix 20 mg IV 30
minutes prior to the examination
D. No special orders are necessary for this
examination
20. The nurse is giving discharge
teaching to a client 7 days post
myocardial infarction. He asks the nurse
why he must wait 6 weeks before having
sexual intercourse. What is the best
response by the nurse to this question?
A.  “You need to regain your strength before
attempting such exertion.”
B. “When you can climb 2 flights of stairs
without problems, it is generally safe.”
C. “Have a glass of wine to relax you, then you
can try to have sex.”
D.  “If you can maintain an active walking
program, you will have less risk.”
21. A triage nurse has these 4 clients
arrive in the emergency department within
15 minutes. Which client should the triage
nurse send back to be seen first?
A. A 2 month old infant with a history of rolling
off the bed and has bulging fontanels with
crying
B. A teenager who got a singed beard while
camping
C. An elderly client with complaints of frequent
liquid brown colored stools
D. A middle aged client with intermittent pain
behind the right scapula
22. While planning care for a toddler, the
nurse teaches the parents about the
expected developmental changes for this
age. Which statement by the mother
shows that she understands the child’s
developmental needs?
A. “I want to protect my child from any falls.”
B. “I will set limits on exploring the house.”
C. “I understand the need to use those new
skills.”
D. “I intend to keep control over our child.”
23. The nurse is preparing to administer
an enteral feeding to a client via a
nasogastric feeding tube. The most
important action of the nurse is
A. Verify correct placement of the tube
B. Check that the feeding solution matches the
dietary order
C. Aspirate abdominal contents to determine the
amount of last feeding remaining in stomach
D. Ensure that feeding solution is at room
temperature
24. The nurse is caring for a client with a
serum potassium level of 3.5 mEq/L. The
client is placed on a cardiac monitor and
receives 40 mEq KCL in 1000 ml of 5%
dextrose in water IV. Which of the
following EKG patterns indicates to the
nurse that the infusions should be
discontinued?
A. Narrowed QRS complex
B. Shortened “PR” interval
C. Tall peaked T waves
D. Prominent “U” waves
25. A nurse prepares to care for a 4 year-
old newly admitted for
rhabdomyosarcoma. The nurse should
alert the staff to pay more attention to the
function of which area of the body?
A. All striated muscles
B. The cerebellum
C. The kidneys
D. The leg bones
26. The nurse anticipates that for a family
who practices Chinese medicine the
priority goal would be to
A. Achieve harmony
B. Maintain a balance of energy
C. Respect life
D. Restore yin and yang
27. During an assessment of a client with
cardiomyopathy, the nurse finds that the
 systolic blood pressure has decreased A. Excessive fetal weight
from 145 to 110 mm Hg and the heart B. Low blood sugar levels
C. Depletion of subcutaneous fat
rate has risen from 72 to 96 beats per
D. Progressive placental insufficiency
minute and the client complains of
33. The nurse is caring for a client who
periodic dizzy spells. The nurse instructs
had a total hip replacement 4 days ago.
the client to
Which assessment requires the nurse’s
A. Increase fluids that are high in protein immediate attention?
B. Restrict fluids
C. Force fluids and reassess blood pressure A. I have bad muscle spasms in my lower leg of
D.  Limit fluids to non-caffeine beverages the affected extremity.
B. “I just can’t ‘catch my breath’ over the past
28. A client has a Swan-Ganz catheter in
few minutes and I think I am in grave
place. The nurse understands that this is danger.”
intended to measure C. “I have to use the bedpan to pass my water at
least every 1 to 2 hours.”
A. Right heart function
D. “It seems that the pain medication is not
B. Left heart function
working as well today.”
C. Renal tubule function
D. Carotid artery function 34. A client has been taking furosemide
29. A nurse enters a client’s room to (Lasix) for the past week. The nurse
discover that the client has no pulse or recognizes which finding may indicate the
respirations. After calling for help, the first client is experiencing a negative side
action the nurse should take is effect from the medication?

A. Start a peripheral IV A. Weight gain of 5 pounds

B. Initiate closed-chest massage B. Edema of the ankles
C. Establish an airway C. Gastric irritability
D. Obtain the crash cart D. Decreased appetite
30. A client is receiving digoxin (Lanoxin) 35. A client who is pregnant comes to the
0.25 mg. Daily. The health care provider clinic for a first visit. The nurse gathers
has written a new order to give metoprolol data about her obstetric history, which
(Lopressor) 25 mg. B.I.D. In assessing includes 3 year-old twins at home and a
the client prior to administering the miscarriage 10 years ago at 12 weeks
medications, which of the following should gestation. How would the nurse
the nurse report immediately to the health accurately document this information?
care provider? A. Gravida 4 para 2
B. Gravida 2 para 1
A. Blood pressure 94/60
C. Gravida 3 para 1
B. Heart rate 76
D. Gravida 3 para 2
C. Urine output 50 ml/hour
D. Respiratory rate 16 36. The nurse is caring for a client with a
31. While assessing a 1 month-old infant, venous stasis ulcer. Which nursing
which finding should the nurse report intervention would be most effective in
immediately? promoting healing?

A. Abdominal respirations A. Apply dressing using sterile technique

B. Irregular breathing rate B. Improve the client’s nutrition status
C. Inspiratory grunt C. Initiate limb compression therapy
D. Increased heart rate with crying D. Begin proteolytic debridement
32. The nurse practicing in a maternity 37. A nurse is to administer meperidine
setting recognizes that the post mature hydrochloride (Demerol) 100 mg, atropine
fetus is at risk due to sulfate (Atropisol) 0.4 mg, and
 promethizine hydrochloride (Phenergan)
50 mg IM to a pre-operative client. Which
action should the nurse take first?
A. Raise the side rails on the bed
B. Place the call bell within reach
C.  Instruct the client to remain in bed
D. Have the client empty bladder
38. Which of these statements best
describes the characteristic of an effective
reward-feedback system?
A. Specific feedback is given as close to the
event as possible
B. Staff are given feedback in equal amounts
over time
C.  Positive statements are to precede a negative
statement
D. Performance goals should be higher than what
is attainable
39. A client with multiple sclerosis plans
to begin an exercise program. In addition
to discussing the benefits of regular
exercise, the nurse should caution the
client to avoid activities which
A. Increase the heart rate
B. Lead to dehydration
C. Are considered aerobic
D. May be competitive
40. During the evaluation of the quality of
home care for a client with Alzheimer’s
disease, the priority for the nurse is to
reinforce which statement by a family
member?
A. At least 2 full meals a day is eaten.
B. We go to a group discussion every week at
our community center.
C. We have safety bars installed in the bathroom
and have 24 hour alarms on the doors.
D. The medication is not a problem to have it
taken 3 times a day.
Answers and Rationales
1. The correct answer is A: 45 year-old African
American attorney The incidence of
hypertension is greater among African
Americans than other groups in the US. The
incidence among the Hispanic population is
rising.
2. The correct answer is A: Gastric lavage PRN
Removing as much of the drug as possible is
the first step in treatment for this drug
overdose. This is best done by gastric lavage.
The next drug to give would be activated
charcoal, then mucomyst and lastly the IV
fluids.
3. The correct answer is B: thrombus formation
Thrombus formation in the coronary arteries
is a potential problem in the initial 24 hours
after a cardiac catheterization. A falling BP
occurs along with hemorrhage of the insertion
site which is associated with the first 12 hours
after the procedure.
4. The correct answer is C: Manage pain The
immediate goal of therapy is to alleviate the
client’s pain.
5. The correct answer is D: Yearly weight gain
of about 5.5 pounds per year School age
children gain about 5.5 pounds each year and
increase about 2 inches in height.
6. The correct answer is A: go get a blood
pressure check within the next 48 to 72 hours
The blood pressure reading is moderately high
with the need to have it rechecked in a few
days. The client states it is ‘usually much
lower.’ Thus a concern exists for
complications such as stroke. However
immediate check by the provider of care is not
warranted. Waiting 2 months or a week for
follow-up is too long.
7. The correct answer is A: A middle aged
client with a history of being ventilator
dependent for over 7 years and admitted with
bacterial pneumonia five days ago The best
candidate for discharge is one who has had a
chronic condition and is most familiar with
their care. This client in option A is most
likely stable and could continue medication
therapy at home.
8. The correct answer is A: Should be taken in
the morning Thyroid supplement should be
taken in the morning to minimize the side
effects of insomnia
9. The correct answer is D: Notify the health
care provider of the child”s status These
findings suggest a medical emergency and
may be due to epiglottises. Any child with an
acute onset of an inflammatory response in
the mouth and throat should receive
immediate attention in a facility equipped to
perform intubation or a tracheostomy in the
event of further or complete obstruction.
10.The correct answer is C: Bed wetting In
children, fatigue and bed wetting are the chief
complaints that prompt parents to take their
child for evaluation. Bed wetting in a school
age child is readily detected by the parents.
11.The correct answer is B: Chlamydia
Chlamydial infections are one of the most
frequent causes of salpingitis or pelvic
inflammatory disease.
12.The correct answer is C: An adolescent who
has been on pain medications for terminal
cancer with an initial assessment finding of
pinpoint pupils and a relaxed respiratory rate
of 10 Nurses who are floated to other units
should be assigned to a client who has
minimal anticipated immediate complications
of their problem. The client in option C
exhibits opoid toxicity with the pinpoint
pupils and has the least risk of complications
to occur in the near future.
13.The correct answer is C: Avoiding very
heavy meals eating large, heavy meals can
pull blood away from the heart for digestion
and is dangerous for the client with coronary
artery disease.
14.The correct answer is C: The level of drug is
100 ml at 8 AM and is 80 ml at noon The
minimal dose of 10 ml per hour which would
be 40 ml given in a 4 hour period. Only 60 ml
should be left at noon. The pump is not
functioning when more than expected
medicine is left in the container.
15.The correct answer is B: Spinal column
manipulation The theory underlying
chiropractic is that interference with
transmission of mental impulses between the
brain and body organs produces diseases.
Such interference is caused by misalignment
of the vertebrae. Manipulation reduces the
subluxation.
16.The correct answer is A: Decrease in level of
consciousness A further decrease in the level
of consciousness would be indicative of a
further progression of the CVA.
17.The correct answer is C: Moist, productive
cough Option c is a later sign. Noisy
respirations and a dry non-productive cough
are commonly the first of the respiratory signs
to appear in a newly diagnosed client with
cystic fibrosis (CF). The other options are the
earliest findings. CF is an inherited (genetic)
condition affecting the cells that produce
mucus, sweat, saliva and digestive juices.
Normally, these secretions are thin and
slippery, but in CF, a defective gene causes
the secretions to become thick and sticky.
Instead of acting as a lubricant, the secretions
plug up tubes, ducts and passageways,
especially in the pancreas and lungs.
Respiratory failure is the most dangerous
consequence of CF.
18.The correct answer is B: Send him to the
emergency room for evaluation This client
requires immediate evaluation. A delay in
treatment could result in further deterioration
and harm. Home care nurses must prioritize
interventions based on assessment findings
that are in the client’s best interest.
19.The correct answer is D: No special orders
are necessary for this examination No special
preparation is necessary for this examination.
20.The correct answer is B: “When you can
climb 2 flights of stairs without problems, it is
generally safe.” There is a risk of cardiac
rupture at the point of the myocardial
infarction for about 6 weeks. Scar tissue
should form about that time. Waiting until the
client can tolerate climbing stairs is the usual
advice given by health care providers.
21.The correct answer is B: A teenager who got
singed a singed beard while camping This
client is in the greatest danger with a potential
of respiratory distress, Any client with singed
facial hair has been exposed to heat or fire in
close range that could have caused damage to
the interior of the lung. Note that the interior
lining of the lung has no nerve fibers so the
client will not be aware of swelling.
22.The correct answer is C: “I understand the
need to use those new skills.” Erikson
describes the stage of the toddler as being the
time when there is normally an increase in
autonomy. The child needs to use motor skills
to explore the environment.
23.The correct answer is A: Verify correct
placement of the tube Proper placement of the
tube prevents aspiration.
24.The correct answer is C: Tall peaked T
waves A tall peaked T wave is a sign of
hyperkalemia. The health care provider should
be notified regarding discontinuing the
medication.
25.The correct answer is A: All striated muscles
Rhabdomyosarcoma is the most common
children”s soft tissue sarcoma. It originates in
striated (skeletal) muscles and can be found
anywhere in the body. The clue is in the
middle of the word and is “myo” which
typically means muscle.
26.The correct answer is D: Restore yin and
yang For followers of Chinese medicine,
health is maintained through balance between
the forces of yin and yang.
27.The correct answer is C: Force fluids and
reassess blood pressure Postural hypotension,
a decrease in systolic blood pressure of more
than 15 mm Hg and an increase in heart rate
of more than 15 percent usually accompanied
by dizziness indicates volume depletion,
inadequate vasoconstrictor mechanisms, and
autonomic insufficiency.
28.The correct answer is B: Left heart function
The Swan-Ganz catheter is placed in the
pulmonary artery to obtain information about
the left side of the heart. The pressure
readings are inferred from pressure
measurements obtained on the right side of
the circulation. Right-sided heart function is
assessed through the evaluation of the central
venous pressures (CVP).
29.The correct answer is C: Establish an airway
Establishing an airway is always the primary
objective in a cardiopulmonary arrest.
30.The correct answer is A: Blood pressure
94/60 Both medications decrease the heart
rate. Metoprolol affects blood pressure.
Therefore, the heart rate and blood pressure
must be within normal range (HR 60-100;
systolic B/P over 100) in order to safely
administer both medications.
31.The correct answer is C: Inspiratory grunt
Inspiratory grunting is abnormal and may be a
sign of respiratory distress in this infant.
32.The correct answer is D: Progressive
placental insufficiency The placenta functions
less efficiently as pregnancy continues beyond
42 weeks. Immediate and long term effects
may be related to hypoxia.
33.The correct answer is B: “I just can”t ”catch
my breath” over the past few minutes and I
think I am in grave danger.” The nurse would
be concerned about all of these comments.
However the most life threatening is option B.
Clients who have had hip or knee surgery are
at greatest risk for development of post
operative pulmonary embolism. Sudden
dyspnea and tachycardia are classic findings
of pulmonary embolism. Muscle spasms do
not require immediate attention. Option C
may indicate a urinary tract infection. And
option D requires further investigation and is
not life threatening.
34.The correct answer is D: Decreased appetite
Lasix causes a loss of potassium if a
supplement is not taken. Signs and symptoms
of hypokalemia include anorexia, fatigue,
nausea, decreased GI motility, muscle
weakness, dysrhythmias.
35.The correct answer is C: Gravida 3 para 1
Gravida is the number of pregnancies and
Parity is the number of pregnancies that reach
viability (not the number of fetuses). Thus, for
this woman, she is now pregnant, had 2 prior
pregnancies, and 1 viable birth (twins).
36.The correct answer is B: Improve the
client”s nutrition status The goal of clinical
management in a client with venous stasis
ulcers is to promote healing. This only can be
accomplished with proper nutrition. The other
answers are correct, but without proper
nutrition, the other interventions would be of
little help.
37.The correct answer is D: Have the client
empty bladder The first step in the process is
to have the client void prior to administering
the pre-operative medication. The other
actions follow this initial step in this
sequence: 4 3 1 2
38.The correct answer is A: Specific feedback
is given as close to the event as possible
Feedback is most useful when given
immediately. Positive behavior is
strengthened through immediate feedback,
and it is easier to modify problem behaviors if
the standards are clearly understood.
39.The correct answer is B: Lead to
dehydration The client must take in adequate
fluids before and during exercise periods.
40.The correct answer is C: We have safety
bars installed in the bathroom and have 24
hour alarms on the doors. Ensuring safety of
the client with increasing memory loss is a
priority of home care. Note all options are
correct statements. However, safety is most
important to reinforce.
 NCLEX RN Practice Exam 16 B. “The pain is due to peripheral nervous system
interruptions. I will get you some pain
1. The primary reason for rapid
medication.”
continuous rewarming of the area
C. “The pain is psychological because your foot
affected by frostbite is to:
is no longer there.”
A. Lessen the amount of cellular damage
D. “The pain and itching are due to the infection
B. Prevent the formation of blisters
you had before the surgery.”
C. Promote movement
D. Prevent pain and discomfort 6. A client with cancer of the pancreas
2. A client recently started on has undergone a Whipple procedure. The
hemodialysis wants to know how the nurse is aware that during the Whipple
dialysis will take the place of his kidneys. procedure, the doctor will remove the:
The nurse’s response is based on the A. Head of the pancreas
knowledge that hemodialysis works by: B. Proximal third section of the small intestines
C. Stomach and duodenum
A. Passing water through a dialyzing membrane D. Esophagus and jejunum
B. Eliminating plasma proteins from the blood
7. The physician has ordered a minimal-
C. Lowering the pH by removing nonvolatile
acids bacteria diet for a client with neutropenia.
D. Filtering waste through a dialyzing membrane The client should be taught to avoid
3. During a home visit, a client with AIDS eating:
tells the nurse that he has been exposed A. Fruits
to measles. Which action by the nurse is B. Salt
most appropriate? C. Pepper
D. Ketchup
A. Administer an antibiotic
8. A client is discharged home with a
B. Contact the physician for an order for immune
globulin prescription for Coumadin (sodium
C. Administer an antiviral warfarin). The client should be instructed
D. Tell the client that he should remain in to:
isolation for 2 weeks
4. A client hospitalized with MRSA A. Have a Protime done monthly
B. Eat more fruits and vegetables
(methicillin-resistant staph aureus) is C. Drink more liquids
placed on contact precautions. Which D. Avoid crowds
statement is true regarding precautions 9. The nurse is assisting the physician
for infections spread by contact? with removal of a central venous catheter.
A. The client should be placed in a room with To facilitate removal, the nurse should
negative pressure. instruct the client to:
B. Infection requires close contact; therefore, the
door may remain open. A. Perform the Valsalva maneuver as the catheter
C. Transmission is highly likely, so the client is advanced
should wear a mask at all times. B. Turn his head to the left side and hyperextend
D. Infection requires skin-to-skin contact and is the neck
prevented by hand washing, gloves, and a C. Take slow, deep breaths as the catheter is
gown. removed
D. Turn his head to the right while maintaining a
5. A client who is admitted with an above- sniffing position
the-knee amputation tells the nurse that 10. A client has an order for
his foot hurts and itches. Which response streptokinase. Before administering the
by the nurse indicates understanding of medication, the nurse should assess the
phantom limb pain? client for:
A. “The pain will go away in a few days.”
A. Allergies to pineapples and bananas
B. A history of streptococcal infections place an X on the Tail of Spence.
C. Prior therapy with phenytoin
D. A history of alcohol abuse
11. The nurse is providing discharge
teaching for the client with leukemia. The
client should be told to avoid:
A. Using oil- or cream-based soaps
B. Flossing between the teeth
C. The intake of salt
D. Using an electric razor
12. The nurse is changing the ties of the
client with a tracheotomy. The safest 16. The toddler is admitted with a cardiac
method of changing the tracheotomy ties anomaly. The nurse is aware that the infant
is to: with a ventricular septal defect will:
A. Tire easily
A. Apply the new tie before removing the old B. Grow normally
one. C. Need more calories
B. Have a helper present. D. Be more susceptible to viral infections
C. Hold the tracheotomy with the nondominant 17. The nurse is monitoring a client with a
hand while removing the old tie.
history of stillborn infants. The nurse is
D. Ask the doctor to suture the tracheostomy in
place. aware that a nonstress test can be
13. The nurse is monitoring a client ordered for this client to:
following a lung resection. The hourly A. Determine lung maturity
output from the chest tube was 300mL. B. Measure the fetal activity
The nurse should give priority to: C. Show the effect of contractions on fetal heart
rate
A. Turning the client to the left side D. Measure the well-being of the fetus
B. Milking the tube to ensure patency 18. The nurse is evaluating the client who
C. Slowing the intravenous infusion
was admitted 8 hours ago for induction of
D. Notifying the physician
labor. The following graph is noted on the
14. The infant is admitted to the unit with
monitor. Which action should be taken
tetrology of falot. The nurse would
first by the nurse?
anticipate an order for which medication?
A. Digoxin
B. Epinephrine
C. Aminophyline
D. Atropine
15. The nurse is educating the lady’s club
in self-breast exam. The nurse is aware
that most malignant breast masses occur
in the Tail of Spence. On the diagram,

A. Instruct the client to push

B. Perform a vaginal exam
C. Turn off the Pitocin infusion
D. Place the client in a semi-Fowler’s position
19. The nurse notes the following on the ECG
monitor. The nurse would evaluate the cardiac
 arrhythmia as:
A. Atrial flutter
B. A sinus rhythm
C. Ventricular tachycardia
D. Atrial fibrillation
20. A client with clotting disorder has an
order to continue Lovenox (enoxaparin)
injections after discharge. The nurse should
teach the client that Lovenox injections
should:
A. Be injected into the deltoid muscle
B. Be injected into the abdomen
C. Aspirate after the injection
D. Clear the air from the syringe before
injections
21. The nurse has a preop order to
administer Valium (diazepam) 10mg and
Phenergan (promethazine) 25mg. The
correct method of administering these
medications is to:
A. Administer the medications together in one
syringe
B. Administer the medication separately
C. Administer the Valium, wait 5 minutes, and
then inject the Phenergan
D. Question the order because they cannot be
given at the same time
22. A client with frequent urinary tract
infections asks the nurse how she can
prevent the reoccurrence. The nurse
should teach the client to:
A. Douche after intercourse
B. Void every 3 hours
C. Obtain a urinalysis monthly
D. Wipe from back to front after voiding
23. Which task should be assigned to the
nursing assistant?
A. Placing the client in seclusion
B. Emptying the Foley catheter of the
preeclamptic client
C. Feeding the client with dementia
D. Ambulating the client with a fractured hip
24. The client has recently returned from
having a thyroidectomy. The nurse should
keep which of the following at the
bedside?
A. A tracheotomy set
B. A padded tongue blade
C. An endotracheal tube
D. An airway
25. The physician has ordered a
histoplasmosis test for the elderly client.
The nurse is aware that histoplasmosis is
transmitted to humans by:
A. Cats
B. Dogs
C. Turtles
D. Birds
Answers and Rationales
1. Answer A is correct. Rapid continuous
rewarming of a frostbite primarily lessens
cellular damage. It does not prevent formation
of blisters. It does promote movement, but
this is not the primary reason for rapid
rewarming. It might increase pain for a short
period of time as the feeling comes back into
the extremity; therefore, answers B, C, and D
are incorrect.
2. Answer D is correct. Hemodialysis works by
using a dialyzing membrane to filter waste
that has accumulated in the blood. It does not
pass water through a dialyzing membrane nor
does it eliminate plasma proteins or lower the
pH, so answers A, B, and C are incorrect.
3. Answer B is correct. The client who is
immune-suppressed and is exposed to measles
should be treated with medications to boost
his immunity to the virus. An antibiotic or
antiviral will not protect the client and it is too
late to place the client in isolation, so answers
A, C, and D are incorrect.
4. Answer D is correct. The client with MRSA
should be placed in isolation. Gloves, a gown,
and a mask should be used when caring for
the client and hand washing is very important.
The door should remain closed, but a
negative-pressure room is not necessary, so
answers A and B are incorrect. MRSA is
spread by contact with blood or body fluid or
by touching the skin of the client. It is
cultured from the nasal passages of the client,
so the client should be instructed to cover his
nose and mouth when he sneezes or coughs. It
is not necessary for the client to wear the
mask at all times; the nurse should wear the
mask, so answer C is incorrect.
5. Answer B is correct. Pain related to phantom
limb syndrome is due to peripheral nervous
system interruption. Answer A is incorrect
because phantom limb pain can last several
 months or indefinitely. Answer C is incorrect
because it is not psychological. It is also not
due to infections, as stated in answer D.
6. Answer A is correct. During a Whipple
procedure the head of the pancreas, which is a
part of the stomach, the jejunum, and a
portion of the stomach are removed and
reanastomosed. Answer B is incorrect because
the proximal third of the small intestine is not
removed. The entire stomach is not removed,
as in answer C, and in answer D, the
esophagus is not removed.
7. Answer C is correct. Pepper is not processed
and contains bacteria. Answers A, B, and D
are incorrect because fruits should be cooked
or washed and peeled, and salt and ketchup
are allowed.
8. Answer A is correct. Coumadin is an
anticoagulant. One of the tests for bleeding
time is a Protime. This test should be done
monthly. Eating more fruits and vegetables is
not necessary, and dark-green vegetables
contain vitamin K, which increases clotting,
so answer B is incorrect. Drinking more
liquids and avoiding crowds is not necessary,
so answers C and D are incorrect.
9. Answer A is correct. The client who is
having a central venous catheter removed
should be told to hold his breath and bear
down. This prevents air from entering the line.
Answers B, C, and D will not facilitate
removal.
10.Answer B is correct. Clients with a history of
streptococcal infections could have antibodies
that render the streptokinase ineffective. There
is no reason to assess the client for allergies to
pineapples or bananas, there is no correlation
to the use of phenytoin and streptokinase, and
a history of alcohol abuse is also not a factor
in the order for streptokinase; therefore,
answers A, C, and D are incorrect.
11.Answer B is correct. The client who is
immune-suppressed and has bone marrow
suppression should be taught not to floss his
teeth because platelets are decreased. Using
oils and cream-based soaps is allowed, as is
eating salt and using an electric razor;
therefore, answers A, C, and D are incorrect.
12.Answer A is correct. The best method and
safest way to change the ties of a tracheotomy
is to apply the new ones before removing the
old ones. Having a helper is good, but the
helper might not prevent the client from
coughing out the tracheotomy. Answer C is
not the best way to prevent the client from
coughing out the tracheotomy. Asking the
doctor to suture the tracheotomy in place is
not appropriate.
13.Answer D is correct. The output of 300mL is
indicative of hemorrhage and should be
reported immediately. Answer A does nothing
to help the client. Milking the tube is done
only with an order and will not help in this
situation, and slowing the intravenous
infusion is not correct; thus, answers B and C
are incorrect.
14.Answer A is correct. The infant
with Tetralogy of Fallot involves four heart
defects: A large ventricular septal defect
(VSD), Pulmonary stenosis, Right ventricular
hypertrophy and, An overriding aorta. He will
be treated with digoxin to slow and strengthen
the heart. Epinephrine, aminophyline, and
atropine will speed the heart rate and are not
used in this client; therefore, answers B, C,
and D are incorrect.
15.The correct answer is marked by an X in
the diagram. The Tail of Spence is located in
the upper outer quadrant of the breast.
16.Answer A is correct. The toddler with a
ventricular septal defect will tire easily. He
will not grow normally but will not need more
calories. He will be susceptible to bacterial
infection, but he will be no more susceptible
to viral infections than other children.
Therefore, answers B, C, and D are incorrect.
17.Answer B is correct. A nonstress test
determines periodic movement of the fetus. It
does not determine lung maturity, show
contractions, or measure neurological well-
being, making answers A, C, and D incorrect.
18.Answer C is correct. The monitor indicates
variable decelerations caused by cord
compression. If Pitocin is infusing, the nurse
should turn off the Pitocin. Instructing the
client to push is incorrect because pushing
could increase the decelerations and because
the client is 8cm dilated, making answer A
incorrect. Performing a vaginal exam should
be done after turning off the Pitocin, and
placing the client in a semi-Fowler’s position
is not appropriate for this situation; therefore,
answers B and D are incorrect.
19.Answer C is correct. The graph indicates
ventricular tachycardia. The answers in A, B,
and D are not noted on the ECG strip.
20.Answer B is correct. Lovenox injections
should be given in the abdomen, not in the
deltoid muscle. The client should not aspirate
after the injection or clear the air from the
 syringe before injection. Therefore, answers
A, C, and D are incorrect.
21.Answer B is correct. Valium is not given in
the same syringe with other medications, so
answer A is incorrect. These medications can
be given to the same client, so answer D is
incorrect. In answer C, it is not necessary to
wait to inject the second medication. Valium
is an antianxiety medication, and Phenergan is
used as an antiemetic.
22.Answer B is correct. Voiding every 3 hours
prevents stagnant urine from collecting in the
bladder, where bacteria can grow. Douching is
not recommended and obtaining a urinalysis
monthly is not necessary, making answers A
and C incorrect. The client should practice
wiping from front to back after voiding and
bowel movements, so answer D is incorrect.
23.Answer C is correct. Of these clients, the one
who should be assigned to the care of the
nursing assistant is the client with dementia.
Only an RN or the physician can place the
client in seclusion, so answer A is incorrect.
The nurse should empty the Foley catheter of
the preeclamptic client because the client is
unstable, making answer B incorrect. A nurse
or physical therapist should ambulate the
client with a fractured hip, so answer D is
incorrect.
24.Answer A is correct. The client who has
recently had a thyroidectomy is at risk for
tracheal edema. A padded tongue blade is
used for seizures and not for the client with
tracheal edema, so answer B is incorrect. If
the client experiences tracheal edema, the
endotracheal tube or airway will not correct
the problem, so answers C and D are
incorrect.
25.Answer D is correct. Histoplasmosis is a
fungus carried by birds. It is not transmitted to
humans by cats, dogs, or turtles. Therefore,
answers A, B, and C are incorrect.
 NCLEX RN Practice Exam 17 D. Heparin-associated thrombosis and
thrombocytopenia (HATT).
1. What’s the first intervention for a
7. A 16-year-old patient involved in a
patient experiencing chest pain and an
motor vehicle accident arrives in the ED
5p02 of 89%?
unconscious and severely hypotensive.
A. Administer morphine. He’s suspected to have several fractures
B. Administer oxygen. of his pelvis and legs. Which of the
C. Administer sublingual nitroglycerin. following parenteral fluids is the best
D. Obtain an electrocardiogram (ECC)
choice for his current condition?
2. Which of the following signs and
symptoms usually signifies rapid A. Fresh frozen plasma.
expansion and impending rupture of an B. 0.9% sodium chloride solution.
C. Lactated Ringer’s solution.
abdominal aortic aneurysm?
D. Packed red blood cells.
A. Abdominal pain. 8. Corticosteroids are potent suppressors
B. Absent pedal pulses. of the body’s inflammatory response.
C. Chest pain. Which of the following conditions or
D. Lower back pain.
actions do they suppress?
3. In which of the following types of
cardiomyopathy does cardiac output A. Cushing syndrome.
remain normal? B. Pain receptors.
C. Immune response.
A. Dilated. D. Neural transmission.
B. Hypertrophic. 9. A patient infected with human
C. Obliterative. immunodeficiency virus (HIV) begins
D. Restrictive.
zidovudine therapy. Which of the
4. Which of the following interventions
following statements best describes this
should be your first priority when treating
drug’s action?
a patient experiencing chest pain while
walking? A. It destroys the outer wall of the virus and kills
it.
A. Have the patient sit down. B. It interferes with viral replication.
B. Get the patient back to bed. C. It stimulates the immune system.
C. Obtain an ECG. D. It promotes excretion of viral antibodies.
D. Administer sublingual nitroglycerin. 10. A 20-year-old patient is being treated
5. Which of the following positions would for pneumonia. He has a persistent cough
best aid breathing for a patient with acute and complains of severe pain on
pulmonary edema? coughing. What could you tell him to help
A. Lying flat in bed. him reduce his discomfort?
B. Left side-lying position.
A. “Hold your cough as much as possible.”
C. High Fowler’s position.
B. “Place the head of your bed flat to help with
D. Semi-Fowler’s position.
coughing.”
6. A pregnant woman arrives at the C. “Restrict fluids to help decrease the amount of
emergency department (ED) with abruptio sputum.”
placentae at 34 weeks’ gestation. She’s D.  “Splint your chest wall with a pillow for
at risk for which of the following blood comfort.”
dyscrasias? 11. A 19-year-old patient comes to the ED
with acute asthma. His respiratory rate is
A. Thrombocytopenia. 44 breaths/minute, and he appears to be
B. Idiopathic thrombocytopenic purpura (ITP).
C. Disseminated intravascular coagulation (DIC). in acute respiratory distress. Which of the
following actions should you take first?
A. Take a full medical history. 17. After surgical repair of a hip, which of
B. Give a bronchodilator by nebulizer. the following positions is best for the
C. Apply a cardiac monitor to the patient.
patient’s legs and hips?
D. Provide emotional support for the patient.
12. A firefighter who was involved in A. Abduction.
extinguishing a house fire is being treated B. Adduction.
for smoke inhalation. He develops severe C. Prone.
D. Subluxated.
hypoxia 48 hours after the incident,
18. Which of the following factors should
requiring intubation and mechanical
be the primary focus of nursing
ventilation. Which of the following
management in a patient with acute
conditions has he most likely developed?
pancreatitis?
A. Acute respiratory distress syndrome (ARDS).
B. Atelectasis. A. Nutrition management.
C. Bronchitis. B. Fluid and electrolyte balance.
D. Pneumonia. C. Management of hypoglycemia.
D. Pain control.
13. Which of the following measures best
determines that a patient who had a 19. After a liver biopsy, place the patient
pneumothorax no longer needs a chest in which of the following positions?
tube? A. Left side-lying, with the bed flat.
B. Right side-lying, with the bed flat.
A. You see a lot of drainage from the chest tube. C. Left side-lying, with the bed in semi-Fowler’s
B. Arterial blood gas (ABG) levels are normal. position.
C. The chest X-ray continues to show the lung is D. Right side-lying, with the bed in semi-
35% deflated. Fowler’s position.
D. The water-seal chamber doesn’t fluctuate
when no suction is applied. 20. Which of the following potentially
serious complications could occur with
14. Which of the following nursing
therapy for hypothyroidism?
interventions should you use to prevent
footdrop and contractures in a patient A. Acute hemolytic reaction.
recovering from a subdural hematoma? B. Angina or cardiac arrhythmia.
C. Retinopathy.
A. High-top sneakers. D.  Thrombocytopenia.
B. Low-dose heparin therapy. 21. Adequate fluid replacement and
C. Physical therapy consultation.
D. Sequential compressive device. vasopressin replacement are objectives
15. Which of the following signs of of therapy for which of the following
increased intracranial pressure (ICP) disease processes?
would appear first after head trauma? A. Diabetes mellitus.
B. Diabetes insipidus.
A. Bradycardia. C. Diabetic ketoacidosis.
B. Large amounts of very dilute urine. D. Syndrome of inappropriate antidiuretic
C. Restlessness and confusion. hormone secretion (SIADH).
D. Widened pulse pressure.
22. Patients with Type 1 diabetes mellitus
16. When giving intravenous (I.V.)
may require which of the following
phenytoin, which of the following methods
changes to their daily routine during
should you use?
periods of infection?
A. Use an in-line filter.
A. No changes.
B. Withhold other anticonvulsants.
C. Mix the drug with saline solution only. B. Less insulin.
C. More insulin.
D. Flush the I.V. catheter with dextrose solution.
D. Oral diabetic agents.
 23. On a follow-up visit after having a
vaginal hysterectomy, a 32-year-old
patient has a decreased hematocrit level.
Which of the following complications does
this suggest?
A. Hematoma.
B. Hypovolemia.
C. Infection.
D. Pulmonary embolus (PE).
24. A patient has partial-thickness burns
to both legs and portions of his trunk.
Which of the following I.V. fluids is given
first?
A. Albumin.
B. D5W.
C. Lactated Ringer’s solution.
D. 0.9% sodium chloride solution with 2 mEq of
potassium per 100 ml.
25. Which of the following techniques is
correct for obtaining a wound culture
specimen from a surgical site?
A. Thoroughly irrigate the wound before
collecting the specimen.
B. Use a sterile swab and wipe the crusty area
around the outside of the wound.
C. Gently roll a sterile swab from the center of
the wound outward to collect drainage.
D. Use a sterile swab to collect drainage from the
dressing
Answers and Rationales
1. B  Administering supplemental oxygen to the
patient is the first priority.  Administer oxygen
to increase SpO to greater than 90% to help
2 
prevent further cardiac damage.  Sublingual
nitroglycerin and morphine are commonly
administered after oxygen.
2. D  Lower back pain results from expansion of
the aneurysm.  The expansion applies pressure
in the abdomen, and the pain is referred to the
lower back.  Abdominal pain is the most
common symptom resulting from impaired
circulation.  Absent pedal pulses are a sign of
no circulation and would occur after a
ruptured aneurysm or in peripheral vascular
disease.  Chest pain usually is associated with
coronary artery or pulmonary disease.
3. B  Cardiac output isn’t affected by
hypertrophic cardiomyopathy because the size
of the ventricle remains relatively unchanged.  11.B  The patient having an acute asthma attack
Dilated cardiomyopathy, obliterative
cardiomyopathy, and restrictive
cardiomyopathy all decrease cardiac output.
4. A The initial priority is to decrease oxygen
consumption by sitting the patient down. 
Administer sublingual nitroglycerin as you
simultaneously do the ECG.  When the
patient’s condition is stabilized, he can be
returned to bed.
5. C High Fowler’s position facilitates breathing
by reducing venous return.  Lying flat and
side-lying positions worsen breathing and
increase the heart’s workload.
6. C Abruptio placentae is a cause of DIC
because it activates the clotting cascade after
hemorrhage.  Thrombocytopenia results from
decreased production of platelets.  ITP doesn’t
have a definitive cause.  A patient with
abruptio placentae wouldn’t get heparin and,
as a result, wouldn’t be at risk for HATT.
7. D  In a trauma situation, the first blood
product given is unmatched (0 negative)
packed red blood cells.  Fresh frozen plasma
often is used to replace clotting factors. 
Lactated Ringer’s solution or 0.9% sodium
chloride is used to increase volume and blood
pressure, but too much of these crystalloids
will dilute the blood and won’t improve
oxygen-carrying capacity.
8. C  Corticosteroids suppress eosinophils,
lymphocytes, and natural-killer cells,
inhibiting the natural inflammatory process in
an infected or injured part of the body.  This
helps resolve inflammation, stabilizes
lysosomal membranes, decreases capillary
permeability, and depresses phagocytosis of
tissues by white blood cells, thus blocking the
release of more inflammatory materials. 
Excessive corticosteroid therapy can lead to
Cushing syndrome.
9. B  Zidovudine inhibits DNA synthesis in
HIV, thus interfering with viral replication. 
The drug doesn’t destroy the viral wall,
stimulate the immune system, or promote HIV
antibody excretion.
10.D  Showing this patient how to splint his chest
wall will help decrease discomfort when
coughing.  Holding in his coughs will only
increase his pain.  Placing the head of the bed
flat may increase the frequency of his cough
and his work of breathing.  Increasing fluid
intake will help thin his secretions, making it
easier for him to clear them.
needs more oxygen delivered to his lungs and
body.  Nebulized bronchodilators open
 airways and increase the amount of oxygen
delivered.  The patient may not need cardiac
monitoring because he’s only 19 years old,
unless he has a medical history of cardiac
problems.
12.A  Severe hypoxia after smoke inhalation
typically is related to ARDS.  The other
choices aren’t typically associated with smoke
inhalation.
13.D  The chest tube isn’t removed until the
patient’s lung has adequately reexpanded and
is expected to stay that way.  One indication
of reexpansion is the cessation of fluctuation
in the water-seal chamber when suction isn’t
applied.  The chest X-ray should show that the
lung is reexpanded.  Drainage should be
minimal before the chest tube is removed.  An
ABG test isn’t necessary if clinical assessment
criteria are met.
14.A  High-top sneakers are used to prevent
footdrop and contractures in patients with
neurologic conditions.  A consult with
physical therapy is important to prevent
footdrop, but you can use high-top sneakers
independently.
15.C  The earliest sign of increased ICP is a
change in mental status.  Bradycardia and
widened pulse pressure occur later.  The
patient may void a lot of very dilute urine if
his posterior pituitary is damaged.
16.C  Phenytoin is compatible only with saline
solutions; dextrose causes an insoluble
precipitate to form.  You needn’t withhold
additional anticonvulsants or use an in-line
filter.
17. A  After surgical repair of the hip, keep the
legs and hips abducted to stabilize the
prosthesis in the acetabulum.
18.B  Acute pancreatitis is commonly associated
with fluid isolation and accumulation in the
bowel secondary to ileus or peripancreatic
edema.  Fluid and electrolyte loss from
vomiting is a major concern.  Therefore, your
priority is to manage hypovolemia and restore
electrolyte balance.  Pain control and nutrition
also are important.  Patients are at risk for
hyperglycemia, not hypoglycemia.
19.B  Positioning the patient on his right side
with the bed flat will splint the biopsy site and
minimize bleeding.  The other positions won’t
do this and may cause more bleeding at the
site or internally.
20.B  Precipitation of angina or cardiac
arrhythmia is a potentially serious
complication of hypothyroidism treatment. 
Acute hemolytic reaction is a complication of
blood transfusions.  Retinopathy typically is a
complication of diabetes mellitus. 
Thrombocytopenia doesn’t result from
treating hypothyroidism.
21.B  Maintaining adequate fluid and replacing
vasopressin are the main objectives in treating
diabetes insipidus.  An excess of antidiuretic
hormone leads to SIADH, causing the patient
to retain fluid.  Diabetic ketoacidosis is a
result of severe insulin insufficiency.
22.C  During periods of infection or illness,
patients with Type 1 diabetes may need even
more insulin to compensate for increased
blood glucose levels.
23.A  A decreased hematocrit level is a sign of
hematoma, a delayed complication of
abdominal and vaginal hysterectomy. 
Symptoms of hypovolemia include increased
hematocrit and hemoglobin values. 
Symptoms of a PE include dyspnea, chest
pain, cough, hemoptysis, restlessness, and
signs of shock.
24.C  Lactated Ringer’s solution replaces lost
sodium and corrects metabolic acidosis, both
of which commonly occur following a burn. 
Albumin is used as adjunct therapy, not
primary fluid replacement.  Dextrose isn’t
given to burn patients during the first 24 hours
because it can cause pseudodiabetes.  The
patient is hyperkalemic from the potassium
shift from the intracellular space to the
plasma, so potassium would be detrimental.
25.C  Rolling a swab from the center outward is
the right way to obtain a culture specimen
from a wound.  Irrigating the wound washes
away drainage, debris, and many of the
colonizing or infecting microorganisms.  The
outside of the wound and the dressing may be
colonized with microorganisms that haven’t
affected the wound, so specimens from these
sites could give inaccurate results.
 NCLEX RN Practice Exam 18
1. A nurse is working in an outpatient
orthopedic clinic. During the patient’s
history the patient reports, “I tore 3 of my
4 Rotator cuff muscles in the past.” Which
of the following muscles cannot be
considered as possibly being torn?
A. Teres minor
B. Teres major
C. Supraspinatus
D. Infraspinatus
2. A nurse at outpatient clinic is returning
phone calls that have been made to the
clinic. Which of the following calls should
have the highest priority for medical
intervention?
A. A home health patient reports, “I am starting
to have breakdown of my heels.”
B. A patient that received an upper extremity
cast yesterday reports, “I can’t feel my fingers
in my right hand today.”
C.  A young female reports, ”I think I sprained
my ankle about 2 weeks ago.”
D. A middle-aged patient reports, ”My knee is
still hurting from the TKR.”
3. A nurse working a surgical unit, notices
a patient is experiencing SOB, calf pain,
and warmth over the posterior calf. All of
these may indicate which of the following
medical conditions?
A. Patient may have a DVT.
B. Patient may be exhibiting signs of dermatitis.
C. Patient may be in the late phases of CHF.
D. Patient may be experiencing anxiety after
surgery.
4. A nurse is performing a screening on a
patient that has been casted recently on
the left lower extremity. Which of the
following statements should the nurse be
most concerned about?
A. The patient reports, “I didn’t keep my
extremity elevated like the doctor asked me
to.”
B. The patient reports, “I have been having pain
in my left calf.”
C. The patient reports, “My left leg has really
been itching.”
D. The patient reports, “The arthritis in my wrists
is flaring up, when I put weight on my
crutches.”
5. A 93 year-old female with a history of
Alzheimer’s Disease gets admitted to an
Alzheimer’s unit. The patient has
exhibited signs of increased confusion
and limited stability with gait. Moreover,
the patient is refusing to use a w/c. Which
of the following is the most appropriate
course of action for the nurse?
A. Recommend the patient remain in her room at
all times.
B. Recommend family members bring pictures to
the patient’s room.
C. Recommend a speech therapy consult to the
doctor.
D. Recommend the patient attempt to walk
pushing the w/c for safety.
6. A nurse is covering a pediatric unit and
is responsible for a 15 year-old male
patient on the floor. The mother of the
child states, “I think my son is sexually
interested in girls.” The most appropriate
course of action of the nurse is to respond
by stating:
A. “I will talk to the doctor about it.”
B. “Has this been going on for a while?”
C. “How do you know this?”
D. “Teenagers often exhibit signs of sexual
interest in females.”
7. A high school nurse observes a 14
year-old female rubbing her scalp
excessively in the gym. The most
appropriate course of action for the nurse
to do is:
A. Request a private evaluation of the female’s
scalp from her parents.
B. Contact the female’s parents about your
observations.
C. Observe the hairline and scalp for possible
signs of lice.
D. Contact the student’s physician.
8. A nurse is caring for a patient who has
recently been diagnosed with fibromyalgia
and COPD. Which of the following tasks
should the nurse delegate to a nursing
assistant?
A. Transferring the patient to the shower.
B. Ambulating the patient for the first time.
C. Taking the patient’s breath sounds
D. Educating the patient on monitoring fatigue
9. A nurse has been instructed to place
an IV line in a patient that has active TB
and HIV. The nurse should where which
of the following safety equipment?
A. Sterile gloves, mask, and goggles
B. Surgical cap, gloves, mask, and proper
shoewear
C. Double gloves, gown, and mask
D. Goggles, mask, gloves, and gown
10. A nurse is instructing a person who
had a left CVA and right lower extremity
hemiparesis to use a quad cane. Which of
the following is the most appropriate gait
sequence?
A. Place the cane in the patient’s left upper
extremity, encourage cane, then right lower
extremity, then left upper extremity gait
sequence.
B. Place the cane in the patient’s left upper
extremity, encourage cane, then left lower
extremity, then right upper extremity gait
sequence.
C. Place the cane in the patient’s right upper
extremity, encourage cane, then right lower
extremity, then left upper extremity gait
sequence.
D. Place the cane in the patient’s right upper
extremity, encourage cane, then left lower
extremity, then right upper extremity gait
sequence.
11. A nurse has just started on the 7PM
surgical unit shift. Which of the following
patients should the nurse check on first?
A. A 75 year-old female who is scheduled for an
EGD in 10 hours.
B. A 34 year-old male who is complaining of
low back pain following back surgery and has
an onset of urinary incontinence in the last
hour.
C. A 21 year-old male who had a lower
extremity BKA yesterday, following a MVA
and has phantom pain.
D. A 27 year-old female who has received 1.5
units of RBC’s. via transfusion the previous
day.
12. A 64 year-old Alzheimer’s patient has
exhibited excessive cognitive decline
resulting in harmful behaviors. The
physician orders restraints to be placed
on the patient. Which of the following is
the appropriate procedure?
A. Secure the restraints to the bed rails on all
extremities.
B. Notify the physician that restraints have been
placed properly.
C. Communicate with the patient and family the
need for restraints.
D. Position the head of the bed at a 45 degree
angle.
13. A 22 year-old patient in a mental
health lock-down unit under suicide watch
appears happy about being discharged.
Which of the following is probably
happening?
A. The patient is excited about being around
family again.
B. The patient’s suicide plan has probably
progressed.
C. The patient’s plans for the future have been
clarified.
D. The patient’s mood is improving.
14. A patient that has delivered a 8.2 lb.
baby boy 3 days ago via c-section,
reports white patches on her breast that
aren’t going away. Which of the following
medications may be necessary?
A. Nystatin
B. Atropine
C. Amoxil
D. Loritab
15. A 13 year old girl is admitted to the
ER with lower right abdominal discomfort.
The admitting nursing should take which
the following measures first?
A. Administer Loritab to the patient for pain
relief.
B. Place the patient in right sidelying position for
pressure relief.
C. Start a Central Line.
D. Provide pain reduction techniques without
administering medication.
16. A 64 year-old male who has been
diagnosed with COPD, and CHF exhibits
an increase in total body weight of 10 lbs.
over the last few days. The nurse should:
A. Contact the patient’s physician immediately.
B. Check the intake and output on the patient’s
flow sheet.
C. Encourage the patient to ambulate to reduce
lower extremity edema.
D. Check the patient’s vitals every 2 hours.
17. A 32 year-old male with a complaint of
dizziness has an order for Morphine via.
IV. The nurse should do which of the
following first?
A. Check the patient’s chest x-ray results.
B. Retake vitals including blood pressure.
C. Perform a neurological screen on the patient.
D. Request the physician on-call assess the
patient.
18. A patient that has TB can be taken off
restrictions after which of the following
parameters have been met?
A. Negative culture results.
B. After 30 days of isolation.
C. Normal body temperature for 48 hours.
D. Non-productive cough for 72 hours.
19. A nurse teaching a patient with COPD
pulmonary exercises should do which of
the following?
A. Teach purse-lip breathing techniques.
B. Encourage repetitive heavy lifting exercises
that will increase strength.
C. Limit exercises based on respiratory acidosis.
D. Take breaks every 10-20 minutes with
exercises.
20. A patient asks a nurse the following
question. Exposure to TB can be
identified best with which of the following
procedures? Which of the following tests
is the most definitive of TB?
A. Chest x-ray
B. Mantoux test
C. Breath sounds examination
D. Sputum culture for gram-negative bacteria
Answers and Rationales
1. (B) Teres Minor, Infraspinatus, Supraspinatus,
and Subscapularis make up the Rotator Cuff.
2. (B) The patient experiencing neurovascular
changes should have the highest priority. Pain
following a TKR is normal, and breakdown
over the heels is a gradual process. Moreover,
a subacute ankle sprain is almost never a
medical emergency.
3. (A) All of these factors indicate a DVT.
4. (B) Pain may be indicating neurovascular
complication.
5. (B) Stimulation in the form of pictures may
decrease signs of confusion.
6. (D) Adolescents exhibiting signs of sexual
development and interest are normal.
7. (C) Observation of the student’s hair is the
next step.
8. (A) Nursing assistants should be competent on
all transfers.
9. (D) All protective measures must be worn, it
is not required to double glove.
10.(A) The cane should be placed in the patient’s
strong upper extremity, and left arm/right foot
go together, for normal gait.
11.(B) The new onset of urinary incontinence
may require additional medical assessment,
and the physician needs to be notified.
12.(C) Both the family and the patient should
have the need for restraints explained to them.
13.(B) The suicide plan may have been decided.
14.(A) Thrush may be occurring and the patient
may need Nystatin.
15.(D) Do not administer pain medication or start
a central line without MD orders.
16.(B) Check the intake and output prior to
making any decisions about patient care.
17.(B) Dizziness can be a sign of hypotension,
that may a contraindication with Morphine.
18.(A) Negative culture results would indicate
absence of infection.
19.(A) Purse lip breathing will help decrease the
volume of air expelled by increased bronchial
airways.
20.(B) The Mantoux is the most accurate test to
determine the presence of TB.
 NCLEX Practice Exam for Medical Surgical Nursing 2 A. TURP is the most common operation for
BPH.
1. A female client is admitted with a B. Explain the purpose and function of a two-
diagnosis of acute renal failure. She is way irrigation system.
awake, alert, oriented, and complaining of C. Expect bloody urine, which will clear as
severe back pain, nausea and vomiting healing takes place.
and abdominal cramps. Her vital signs D. He will be pain free.
are blood pressure 100/70 mm Hg, pulse 5. Roxy is admitted to the hospital with a
110, respirations 30, and oral temperature possible diagnosis of appendicitis. On
100.4°F (38°C). Her electrolytes are physical examination, the nurse should be
sodium 120 mEq/L, potassium 5.2 mEq/L; looking for tenderness on palpation at
her urinary output for the first 8 hours is McBurney’s point, which is located in the
50 ml. The client is displaying signs of A. left lower quadrant
which electrolyte imbalance? B.  left upper quadrant
C. right lower quadrant
A. Hyponatremia
D. right upper quadrant
B. Hyperkalemia
C. Hyperphosphatemia 6. Mr. Valdez has undergone surgical
D. Hypercalcemia repair of his inguinal hernia. Discharge
2. Assessing the laboratory findings, teaching should include
which result would the nurse most likely A. telling him to avoid heavy lifting for 4 to 6
expect to find in a client with chronic renal weeks
failure? B.  instructing him to have a soft bland diet for
two weeks
A. BUN 10 to 30 mg/dl, potassium 4.0 mEq/L, C.  telling him to resume his previous daily
creatinine 0.5 to 1.5 mg/dl activities without limitations
B. Decreased serum calcium, blood pH 7.2, D.  recommending him to drink eight glasses of
potassium 6.5 mEq/L water daily
C. BUN 15 mg/dl, increased serum calcium,
7. A 30-year-old homemaker fell asleep
creatinine l.0 mg/dl
D. BUN 35 to 40 mg/dl, potassium 3.5 mEq/L, while smoking a cigarette. She sustained
pH 7.35, decreased serum calcium severe burns of the face,neck, anterior
3. Treatment with hemodialysis is ordered chest, and both arms and hands. Using
for a client and an external shunt is the rule of nines, which is the best
created. Which nursing action would be of estimate of total body-surface area
highest priority with regard to the external burned?
shunt? A. 18%
A. Heparinize it daily. B.  22%
B. Avoid taking blood pressure measurements or C.  31%
blood samples from the affected arm. D.  40%
C. Change the Silastic tube daily. 8. Nursing care planning is based on the
D. Instruct the client not to use the affected arm. knowledge that the first 24-48 hours post-
4. Romeo Diaz, age 78, is admitted to the burn are characterized by:
hospital with the diagnosis of benign
A. An increase in the total volume of intracranial
prostatic hyperplasia (BPH). He is plasma
scheduled for a transurethral resection of B. Excessive renal perfusion with diuresis
the prostate (TURP). It would be C. Fluid shift from interstitial space
inappropriate to include which of the D. Fluid shift from intravascular space to the
following points in the preoperative interstitial space
teaching?
 9. If a client has severe bums on the that compensatory mechanisms
upper torso, which item would be a associated with hypovolemia would cause
primary concern? all of the following symptoms EXCEPT
A. Debriding and covering the wounds A. hypertension
B. Administering antibiotics B. oliguria
C. Frequently observing for hoarseness, stridor, C. tachycardia
and dyspnea D. tachypnea
D. Establishing a patent IV line for fluid 15. Maria Sison, 40 years old, single, was
replacement admitted to the hospital with a diagnosis
10. Contractures are among the most of Breast Cancer. She was scheduled for
serious long-term complications of severe radical mastectomy. Nursing care during
burns. If a burn is located on the upper the preoperative period should consist of
torso, which nursing measure would be
least effective to help prevent A. assuring Maria that she will be cured of
cancer
contractures?
B. assessing Maria’s expectations and doubts
A. Changing the location of the bed or the TV C. maintaining a cheerful and optimistic
set, or both, daily environment
B. Encouraging the client to chew gum and blow D. keeping Maria’s visitors to a minimum so she
up balloons can have time for herself
C. Avoiding the use of a pillow for sleep, or 16. Maria refuses to acknowledge that her
placing the head in a position of breast was removed. She believes that
hyperextension her breast is intact under the dressing.
D. Helping the client to rest in the position of
The nurse should
maximal comfort
11. An adult is receiving Total Parenteral A. call the MD to change the dressing so Kathy
Nutrition (TPN). Which of the following can see the incision
assessment is essential? B. recognize that Kathy is experiencing denial, a
normal stage of the grieving process
A. evaluation of the peripheral IV site C. reinforce Kathy’s belief for several days until
B. confirmation that the tube is in the stomach her body can adjust to stress of surgery.
C. assess the bowel sound D. remind Kathy that she needs to accept her
D. fluid and electrolyte monitoring diagnosis so that she can begin rehabilitation
12. Which drug would be least effective in exercises.
lowering a client’s serum potassium 17. A chemotherapeutic agent 5FU is
level? ordered as an adjunct measure to
surgery. Which of the ff. statements about
A. Glucose and insulin
chemotherapy is true?
B. Polystyrene sulfonate (Kayexalate)
C. Calcium glucomite A. it is a local treatment affecting only tumor
D. Aluminum hydroxide cells
13. A nurse is directed to administer a B. it affects both normal and tumor cells
hypotonic intravenous solution. Looking at C. it has been proven as a complete cure for
the following labeled solutions, she cancer
D. it is often used as a palliative measure.
should choose
18. Which is an incorrect statement
A. 0.45% NaCl pertaining to the following procedures for
B. 0.9% NaCl cancer diagnostics?
C. D5W
D. D5NSS A. Biopsy is the removal of suspicious tissue and
14. A patient is hemorrhaging from the only definitive method to diagnose cancer
multiple trauma sites. The nurse expects
B. Ultrasonography detects tissue density
changes difficult to observe by X-ray via
sound waves.
C.  CT scanning uses magnetic fields and radio
frequencies to provide cross-sectional view of
tumor
D.  Endoscopy provides direct view of a body
cavity to detect abnormality.
19. A post-operative complication of
mastectomy is lymphedema. This can be
prevented by
A. ensuring patency of wound drainage tube
B. placing the arm on the affected side in a
dependent position
C. restricting movement of the affected arm
D. frequently elevating the arm of the affected
side above the level of the heart.
20. Which statement by the client
indicates to the nurse that the patient
understands precautions necessary
during internal radiation therapy for
cancer of the cervix?
A. “I should get out of bed and walk around in
my room.”
B. “My 7 year old twins should not come to visit
me while I’m receiving treatment.”
C. “I will try not to cough, because the force
might make me expel the application.”
D. “I know that my primary nurse has to wear
one of those badges like the people in the x-
ray department, but they are not necessary for
anyone else who comes in here.”
21. High uric acid levels may develop in
clients who are receiving chemotherapy.
This is caused by:
A. The inability of the kidneys to excrete the
drug metabolites
B. Rapid cell catabolism
C. Toxic effect of the antibiotic that are given
concurrently
D. The altered blood ph from the acid medium of
the drugs
22. Which of the following interventions
would be included in the care of plan in a
client with cervical implant?
A. Frequent ambulation
B. Unlimited visitors
C. Low residue diet
D. Vaginal irrigation every shift
23. Which nursing measure would avoid
constriction on the affected arm
immediately after mastectomy?
A. Avoid BP measurement and constricting
clothing on the affected arm
B. Active range of motion exercises of the arms
once a day.
C. Discourage feeding, washing or combing with
the affected arm
D. Place the affected arm in a dependent
position, below the level of the heart
24. A client suffering from acute renal
failure has an unexpected increase in
urinary output to 150ml/hr. The nurse
assesses that the client has entered the
second phase of acute renal failure.
Nursing actions throughout this phase
include observation for signs and
symptoms of
A. Hypervolemia, hypokalemia, and
hypernatremia.
B. Hypervolemia, hyperkalemia, and
hypernatremia.
C. Hypovolemia, wide fluctuations in serum
sodium and potassium levels.
D. Hypovolemia, no fluctuation in serum sodium
and potassium levels.
25. An adult has just been brought in by
ambulance after a motor vehicle accident.
When assessing the client, the nurse
would expect which of the following
manifestations could have resulted from
sympathetic nervous system stimulation?
A. A rapid pulse and increased RR
B. Decreased physiologic functioning
C. Rigid posture and altered perceptual focus
D. Increased awareness and attention
26. Ms. Sy undergoes surgery and the
abdominal aortic aneurysm is resected
and replaced with a graft. When she
arrives in the RR she is still in shock. The
nurse’s priority should be :
A. placing her in a trendeleburg position
B. putting several warm blankets on her
C. monitoring her hourly urine output
D. assessing her VS especially her RR
27. A major goal for the client during the
first 48 hours after a severe bum is to
 prevent hypovolemic shock. The best
indicator of adequate fluid balance during
this period is
A. Elevated hematocrit levels.
B. Urine output of 30 to 50 ml/hr.
C. Change in level of consciousness.
D. Estimate of fluid loss through the burn eschar.
28. A thoracentesis is performed on a
chest-injured client, and no fluid or air is
found. Blood and fluids is administered
intravenously (IV), but the client’s vital
signs do not improve. A central venous
pressure line is inserted, and the initial
reading is 20 cm H^O. The most likely
cause of these findings is which of the
following?
A. Spontaneous pneumothorax
B. Ruptured diaphragm
C. Hemothorax
D. Pericardial tamponade
29. Intervention for a pt. who has
swallowed a Muriatic Acid includes all of
the following except;
A. administering an irritant that will stimulate
vomiting
B. aspirating secretions from the pharynx if
respirations are affected
C. neutralizing the chemical
D. washing the esophagus with large volumes of
water via gastric lavage
30. Which initial nursing assessment
finding would best indicate that a client
has been successfully resuscitated after a
cardio-respiratory arrest?
A. Skin warm and dry
B. Pupils equal and react to light
C. Palpable carotid pulse
D. Positive Babinski’s reflex
31. Chemical burn of the eye are treated
with
A. local anesthetics and antibacterial drops for 24
– 36 hrs.
B. hot compresses applied at 15-minute intervals
C. Flushing of the lids, conjunctiva and cornea
with tap or preferably sterile water
D. cleansing the conjunctiva with a small cotton-
tipped applicator
32. The Heimlich maneuver (abdominal
thrust), for acute airway obstruction,
attempts to:
A. Force air out of the lungs
B. Increase systemic circulation
C. Induce emptying of the stomach
D. Put pressure on the apex of the heart
33. John, 16 years old, is brought to the
ER after a vehicular accident. He is
pronounced dead on arrival. When his
parents arrive at the hospital, the nurse
should:
A. ask them to stay in the waiting area until she
can spend time alone with them
B. speak to both parents together and encourage
them to support each other and express their
emotions freely
C. Speak to one parent at a time so that each can
ventilate feelings of loss without upsetting the
other
D. ask the MD to medicate the parents so they
can stay calm to deal with their son’s death.
34. An emergency treatment for an acute
asthmatic attack is Adrenaline 1:1000
given hypodermically. This is given to:
A. increase BP
B. decrease mucosal swelling
C. relax the bronchial smooth muscle
D. decrease bronchial secretions
35. A nurse is performing CPR on an
adult patient. When performing chest
compressions, the nurse understands the
correct hand placement is located over
the
A. upper half of the sternum
B. upper third of the sternum
C. lower half of the sternum
D. lower third of the sternum
36. The nurse is performing an eye
examination on an elderly client. The
client states ‘My vision is blurred, and I
don’t easily see clearly when I get into a
dark room.” The nurse best response is:
A.  “You should be grateful you are not blind.”
B. “As one ages, visual changes are noted as part
of degenerative changes. This is normal.”
C. “You should rest your eyes frequently.”
D.  “You maybe able to improve you vision if
you move slowly.”
37. Which of the following activities is not
encouraged in a patient after an eye
surgery?
A. sneezing, coughing and blowing the nose
B. straining to have a bowel movement
C.  wearing tight shirt collars
D.  sexual intercourse
38. Which of the following indicates poor
practice in communicating with a hearing-
impaired client?
A. Use appropriate hand motions
B. Keep hands and other objects away from your
mouth when talking to the client
C.  Speak clearly in a loud voice or shout to be
heard
D.  Converse in a quiet room with minimal
distractions
39. A client is to undergo lumbar
puncture. Which is least important
information about LP?
A.  Specimens obtained should be labeled in their
proper sequence.
B.  It may be used to inject air, dye or drugs into
the spinal canal.
C.  Assess movements and sensation in the lower
extremities after the
D.  Force fluids before and after the procedure.
40. A client diagnosed with cerebral
thrombosis is scheduled for cerebral
angiography. Nursing care of the client
includes the following EXCEPT
A.  Inform the client that a warm, flushed feeling
and a salty taste may be
B.  Maintain pressure dressing over the site of
puncture and check for
C.  Check pulse, color and temperature of the
extremity distal to the site of
D. Kept the extremity used as puncture site
flexed to prevent bleeding.
41. Which is considered as the earliest
sign of increased ICP that the nurse
should closely observed for?
A. abnormal respiratory pattern
B. rising systolic and widening pulse pressure
C. contralateral hemiparesis and ipsilateral
dilation of the pupils
D. progression from restlessness to confusion
and disorientation to lethargy
42. Which is irrelevant in the
pharmacologic management of a client
with CVA?
A. Osmotic diuretics and corticosteroids are
given to decrease cerebral edema
B. Anticonvulsants are given to prevent seizures
C. Thrombolytics are most useful within three
hours of an occlusive CVA
D. Aspirin is used in the acute management of a
completed stroke.
43. What would be the MOST therapeutic
nursing action when a client’s expressive
aphasia is severe?
A. Anticipate the client wishes so she will not
need to talk
B. Communicate by means of questions that can
be answered by the client shaking the head
C. Keep us a steady flow rank to minimize
silence
D. Encourage the client to speak at every
possible opportunity.
44. A client with head injury is confused,
drowsy and has unequal pupils. Which of
the following nursing diagnosis is most
important at this time?
A. altered level of cognitive function
B. high risk for injury
C. altered cerebral tissue perfusion
D. sensory perceptual alteration
45. Which nursing diagnosis is of the
highest priority when caring for a client
with myasthenia gravis?
A. Pain
B. High risk for injury related to muscle
weakness
C. Ineffective coping related to illness
D. Ineffective airway clearance related to muscle
weakness
46. The client has clear drainage from the
nose and ears after a head injury. How
can the nurse determine if the drainage is
CSF?
A. Measure the ph of the fluid
B. Measure the specific gravity of the fluid
C. Test for glucose
D. Test for chlorides
 47. The nurse includes the important
measures for stump care in the teaching
plan for a client with an amputation.
Which measure would be excluded from
the teaching plan?
A. Wash, dry, and inspect the stump daily.
B. Treat superficial abrasions and blisters
promptly.
C. Apply a “shrinker” bandage with tighter arms
around the proximal end of the affected limb.
D. Toughen the stump by pushing it against a
progressively harder substance (e.g., pillow on
a foot-stool).
48. A 70-year-old female comes to the
clinic for a routine checkup. She is 5 feet
4 inches tall and weighs 180 pounds. Her
major complaint is pain in her joints. She
is retired and has had to give up her
volunteer work because of her discomfort.
She was told her diagnosis was
osteoarthritis about 5 years ago. Which
would be excluded from the clinical
pathway for this client?
A. Decrease the calorie count of her daily diet.
B. Take warm baths when arising.
C.  Slide items across the floor rather than lift
them.
D. Place items so that it is necessary to bend or
stretch to reach them.
49. A client is admitted from the
emergency department with severe-pain
and edema in the right foot. His diagnosis
is gouty arthritis. When developing a plan
of care, which action would have the
highest priority?
A. Apply hot compresses to the affected joints.
B. Stress the importance of maintaining good
posture to prevent deformities.
C. Administer salicylates to minimize the
inflammatory reaction.
D. Ensure an intake of at least 3000 ml of fluid
per day.
50. A client had a laminectomy and spinal
fusion yesterday. Which statement is to
be excluded from your plan of care?
A. Before log rolling, place a pillow under the
client’s head and a pillow between the client’s
legs.
B. Before log rolling, remove the pillow from
under the client’s head and use no pillows
between the client’s legs.
C. Keep the knees slightly flexed while the client
is lying in a semi-Fowler’s position in bed.
D. Keep a pillow under the client’s head as
needed for comfort.
Answers and Rationales
1. Answer: (A) Hyponatremia . The normal
serum sodium level is 135 – 145 mEq/L. The
client’s serum sodium is below normal.
Hyponatremia also manifests itself with
abdominal cramps and nausea and vomiting
2. Answer: (B) Decreased serum calcium,
blood pH 7.2, potassium 6.5
mEq/L. Chronic renal failure is usually the
end result of gradual tissue destruction and
loss of renal function. With the loss of renal
function, the kidneys ability to regulate fluid
and electrolyte and acid base balance results.
The serum Ca decreases as the kidneys fail to
excrete phosphate, potassium and hydrogen
ions are retained.
3. Answer: (B) Avoid taking blood pressure
measurements or blood samples from the
affected arm. In the client with an external
shunt, don’t use the arm with the vascular
access site to take blood pressure readings,
draw blood, insert IV lines, or give injections
because these procedures may rupture the
shunt or occlude blood flow causing damage
and obstructions in the shunt.
4. Answer: (D) He will be pain free. Surgical
interventions involve an experience of pain
for the client which can come in varying
degrees. Telling the pain that he will be pain
free is giving him false reassurance.
5. Answer: (C) right lower quadrant . To be
exact, the appendix is anatomically located at
the Mc Burney’s point at the right iliac area of
the right lower quadrant.
6. Answer: (A) telling him to avoid heavy
lifting for 4 to 6 weeks . The client should
avoid lifting heavy objects and any strenuous
activity for 4-6 weeks after surgery to prevent
stress on the inguinal area. There is no special
diet required. The fluid intake of eight glasses
a day is good advice but is not a priority in
this case.
7. Answer: (C) 31% . Using the Rule of Nine in
the estimation of total body surface burned,
we allot the following: 9% – head; 9% – each
upper extremity; 18%- front chest and
abdomen; 18% – entire back; 18% – each
lower extremity and 1% – perineum.
8. Answer: (D) Fluid shift from intravascular
space to the interstitial space . This period is
the burn shock stage or the hypovolemic
phase. Tissue injury causes vasodilation that
results in increase capillary permeability
making fluids shift from the intravascular to
the interstitial space. This can lead to a
decrease in circulating blood volume or
hypovolemia which decreases renal perfusion
and urine output.
9. Answer: (C) Frequently observing for
hoarseness, stridor, and dyspnea . Burns
located in the upper torso, especially resulting
from thermal injury related to fires can lead to
inhalation burns. This causes swelling of the
respiratory mucosa and blistering which can
lead to airway obstruction manifested by
hoarseness, noisy and difficult breathing.
Maintaining a patent airway is a primary
concern.
10.Answer: (D) Helping the client to rest in the
position of maximal comfort . Mobility and
placing the burned areas in their functional
position can help prevent contracture
deformities related to burns. Pain can
immobilize a client as he seeks the position
where he finds less pain and provides
maximal comfort. But this approach can lead
to contracture deformities and other
complications.
11.Answer: (D) fluid and electrolyte
monitoring . Total parenteral nutrition is a
method of providing nutrients to the body by
an IV route. The admixture is made up of
proteins, carbohydrates, fats, electrolytes,
vitamins, trace minerals and sterile water
based on individual client needs. It is intended
to improve the clients nutritional status.
Because of its composition, it is important to
monitor the clients fluid intake and output
including electrolytes, blood glucose and
weight.
12.Answer: (D) Aluminum
hydroxide . Aluminum hydroxide binds
dietary phosphorus in the GI tract and helps
treat hyperphosphatemia. All the other
medications mentioned help treat
hyperkalemia and its effects.
13.Answer: (A) 0.45% NaCl . Hypotonic
solutions like 0.45% NaCl has a lower tonicity
that the blood; 0.9% NaCl and D5W are
isotonic solutions with same tonicity as the
blood; and D5NSS is hypertonic with a higher
tonicity thab the blood.
14.Answer: (A) hypertension . In hypovolemia,
one of the compenasatory mechanisms is
activation of the sympathetic nervous system
that increases the RR & PR and helps restore
the BP to maintain tissue perfusion but not
cause a hypertension. The SNS stimulation
constricts renal arterioles that increases
release of aldosterone, decreases glomerular
filtration and increases sodium & water
reabsorption that leads to oliguria.
15.Answer: (B) assessing Maria’s expectations
and doubts . Assessing the client’s
expectations and doubts will help lessen her
fears and anxieties. The nurse needs to
encourage the client to verbalize and to listen
and correctly provide explanations when
needed.
16.Answer: (B) recognize that Kathy is
experiencing denial, a normal stage of the
grieving process . A person grieves to a loss
of a significant object. The initial stage in the
grieving process is denial, then anger,
followed by bargaining, depression and last
acceptance. The nurse should show
acceptance of the patient’s feelings and
encourage verbalization.
17.Answer: (B) it affects both normal and
tumor cells . Chemotherapeutic agents are
given to destroy the actively proliferating
cancer cells. But these agents cannot
differentiate the abnormal actively
proliferating cancer cells from those that are
actively proliferating normal cells like the
cells of the bone marrow, thus the effect of
bone marrow depression.
18.Answer: (C) CTscanning uses magnetic
fields and radio frequencies to provide
cross-sectional view of tumor . CT scan uses
narrow beam x-ray to provide cross-sectional
view. MRI uses magnetic fields and radio
frequencies to detect tumors.
19.Answer: (D) frequently elevating the arm
of the affected side above the level of the
heart. . Elevating the arm above the level of
the heart promotes good venous return to the
heart and good lymphatic drainage thus
preventing swelling.
20.Answer: (B) “My 7 year old twins should
not come to visit me while I’m receiving
treatment.” . Children have cells that are
normally actively dividing in the process of
growth. Radiation acts not only against the
abnormally actively dividing cells of cancer
but also on the normally dividing cells thus
 affecting the growth and development of the
child and even causing cancer itself.
21.Answer: (B) Rapid cell catabolism . One of
the oncologic emergencies, the tumor lysis
syndrome, is caused by the rapid destruction
of large number of tumor cells. . Intracellular
contents are released, including potassium and
purines, into the bloodstream faster than the
body can eliminate them. The purines are
converted in the liver to uric acid and released
into the blood causing hyperuricemia. They
can precipitate in the kidneys and block the
tubules causing acute renal failure.
22.Answer: (C) Low residue diet . It is
important for the nurse to remember that the
implant be kept intact in the cervix during
therapy. Mobility and vaginal irrigations are
not done. A low residue diet will prevent
bowel movement that could lead to
dislodgement of the implant. Patient is also
strictly isolated to protect other people from
the radiation emissions
23. Answer: (A) Avoid BP measurement and
constricting clothing on the affected
arm . A BP cuff constricts the blood vessels
where it is applied. BP measurements should
be done on the unaffected arm to ensure
adequate circulation and venous and lymph
drainage in the affected arm
24.Answer: (C) Hypovolemia, wide
fluctuations in serum sodium and
potassium levels. . The second phase of ARF
is the diuretic phase or high output phase. The
diuresis can result in an output of up to
10L/day of dilute urine. Loss of fluids and
electrolytes occur.
25.Answer: (A) A rapid pulse and increased
RR . The fight or flight reaction of the
sympathetic nervous system occurs during
stress like in a motor vehicular accident. This
is manifested by increased in cardiovascular
function and RR to provide the immediate
needs of the body for survival.
26.Answer: (D) assessing her VS especially her
RR . Shock is characterized by reduced tissue
and organ perfusion and eventual organ
dysfunction and failure. Checking on the VS
especially the RR, which detects need for
oxygenation, is a priority to help detect its
progress and provide for prompt management
before the occurrence of complications.
27.Answer: (B) Urine output of 30 to 50
ml/hr. Hypovolemia is a decreased in
circulatory volume. This causes a decrease in
tissue perfusion to the different organs of the
body. Measuring the hourly urine output is the
most quantifiable way of measuring tissue
perfusion to the organs. Normal renal
perfusion should produce 1ml/kg of BW/min.
An output of 30-50 ml/hr is considered
adequate and indicates good fluid balance.
28.Answer: (D) Pericardial
tamponade . Pericardial tamponade occurs
when there is presence of fluid accumulation
in the pericardial space that compresses on the
ventricles causing a decrease in ventricular
filling and stretching during diastole with a
decrease in cardiac output. . This leads to right
atrial and venous congestion manifested by a
CVP reading above normal.
29.Answer: (A) administering an irritant that
will stimulate vomiting . Swallowing of
corrosive substances causes severe irritation
and tissue destruction of the mucous
membrane of the GI tract. Measures are taken
to immediately remove the toxin or reduce its
absorption. For corrosive poison ingestion,
such as in muriatic acid where burn or
perforation of the mucosa may occur, gastric
emptying procedure is immediately instituted,
This includes gastric lavage and the
administration of activated charcoal to absorb
the poison. Administering an irritant with the
concomitant vomiting to remove the
swallowed poison will further cause irritation
and damage to the mucosal lining of the
digestive tract. Vomiting is only indicated
when non-corrosive poison is swallowed.
30.Answer: (C) Palpable carotid
pulse . Presence of a palpable carotid pulse
indicates the return of cardiac function which,
together with the return of breathing, is the
primary goal of CPR. Pulsations in arteries
indicates blood flowing in the blood vessels
with each cardiac contraction. Signs of
effective tissue perfusion will be noted after.
31.Answer: (C) Flushing of the lids,
conjunctiva and cornea with tap or
preferably sterile water . Prompt treatment
of ocular chemical burns is important to
prevent further damage. Immediate tap-water
eye irrigation should be started on site even
before transporting the patient to the nearest
hospital facility. In the hospital, copious
irrigation with normal saline, instillation of
local anesthetic and antibiotic is done.
32.Answer: (A) Force air out of the lungs . The
Heimlich maneuver is used to assist a person
choking on a foreign object. The pressure
from the thrusts lifts the diaphragm, forces air
 out of the lungs and creates an artificial cough
that expels the aspirated material.
33.Answer: (B) speak to both parents together
and encourage them to support each other
and express their emotions freely . Sudden
death of a family member creates a state of
shock on the family. They go into a stage of
denial and anger in their grieving. Assisting
them with information they need to know,
answering their questions and listening to
them will provide the needed support for them
to move on and be of support to one another.
34.Answer: (C) relax the bronchial smooth
muscle . Acute asthmatic attack is
characterized by severe bronchospasm which
can be relieved by the immediate
administration of bronchodilators. Adrenaline
or Epinephrine is an adrenergic agent that
causes bronchial dilation by relaxing the
bronchial smooth muscles.
35.Answer: (C) lower half of the sternum . The
exact and safe location to do cardiac
compression is the lower half of the sternum.
Doing it at the lower third of the sternum may
cause gastric compression which can lead to a
possible aspiration.
36.Answer: (B) “As one ages, visual changes
are noted as part of degenerative changes.
This is normal.” . Aging causes less elasticity
of the lens affecting accommodation leading
to blurred vision. The muscles of the iris
increase in stiffness and the pupils dilate
slowly and less completely so that it takes the
older person to adjust when going to and from
light and dark environment and needs brighter
light for close vision.
37.Answer: (D) sexual intercourse . To reduce
increases in IOP, teach the client and family
about activity restrictions. Sexual intercourse
can cause a sudden rise in IOP.
38.Answer: (C) Speak clearly in a loud voice
or shout to be heard . Shouting raises the
frequency of the sound and often makes
understanding the spoken words difficult. It is
enough for the nurse to speak clearly and
slowly.
39.Answer: (D) Force fluids before and after
the procedure. LP involves the removal of
some amount of spinal fluid. To facilitate CSF
production, the client is instructed to increase
fluid intake to 3L, unless contraindicated, for
24 to 48 hrs after the procedure.
40.Answer: (D) Kept the extremity used as
puncture site flexed to prevent
bleeding.Angiography involves the threading
of a catheter through an artery which can
cause trauma to the endothelial lining of the
blood vessel. The platelets are attracted to the
area causing thrombi formation. This is
further enhanced by the slowing of blood flow
caused by flexion of the affected extremity.
The affected extremity must be kept straight
and immobilized during the duration of the
bedrest after the procedure. Ice bag can be
applied intermittently to the puncture site.
41.Answer: (D) progression from restlessness
to confusion and disorientation to
lethargy . The first major effect of increasing
ICP is a decrease in cerebral perfusion
causing hypoxia that produces a progressive
alteration in the LOC. This is initially
manifested by restlessness.
42.Answer: (D) Aspirin is used in the acute
management of a completed stroke. . The
primary goal in the management of CVA is to
improve cerebral tissue perfusion. Aspirin is a
platelet deaggregator used in the prevention of
recurrent or embolic stroke but is not used in
the acute management of a completed stroke
as it may lead to bleeding.
43.Answer: (D) Encourage the client to speak
at every possible opportunity.Expressive or
motor aphasia is a result of damage in the
Broca’s area of the frontal lobe. It is amotor
speech problem in which the client generally
understands what is said but is unable to
communicate verbally. The patient can best he
helped therefore by encouraging him to
communicate and reinforce this behavior
positively.
44.Answer: (C) altered cerebral tissue
perfusion . The observations made by the
nurse clearly indicate a problem of decrease
cerebral perfusion. Restoring cerebral
perfusion is most important to maintain
cerebral functioning and prevent further brain
damage.
45.Answer: (D) Ineffective airway clearance
related to muscle weakness . Myasthenia
gravis causes a failure in the transmission of
nerve impulses at the neuromuscular junction
which may be due to a weakening or decrease
in acetylcholine receptor sites. This leads to
sporadic, progressive weakness or abnormal
fatigability of striated muscles that eventually
causes loss of function. The respiratory
muscles can become weak with decreased
tidal volume and vital capacity making
breathing and clearing the airway through
coughing difficult. The respiratory muscle
 weakness may be severe enough to require
and emergency airway and mechanical
ventilation.
46.Answer: (C) Test for glucose . The CSF
contains a large amount of glucose which can
be detected by using glucostix. A positive
result with the drainage indicate CSF leakage.
47.Answer: (C) Apply a “shrinker” bandage
with tighter arms around the proximal end
of the affected limb. The “shrinker” bandage
is applied to prevent swelling of the stump. It
should be applied with the distal end with the
tighter arms. Applying the tighter arms at the
proximal end will impair circulation and cause
swelling by reducing venous flow.
48.Answer: (D) Place items so that it is
necessary to bend or stretch to reach
them.Patients with osteoarthritis have
decreased mobility caused by joint pain.
Over-reaching and stretching to get an object
are to be avoided as this can cause more pain
and can even lead to falls. The nurse should
see to it therefore that objects are within easy
reach of the patient.
49.Answer: (D) Ensure an intake of at least
3000 ml of fluid per day. Gouty arthritis is a
metabolic disease marked by urate deposits
that cause painful arthritic joints. The patient
should be urged to increase his fluid intake to
prevent the development of urinary uric acid
stones.
50.Answer: (B) Before log rolling, remove the
pillow from under the client’s head and use
no pillows between the client’s
legs. Following a laminectomy and spinal
fusion, it is important that the back of the
patient be maintained in straight alignment
and to support the entire vertebral column to
promote complete healing.
 NCLEX Practice Exam for Endocrine Disorder 1
1. An agitated, confused female client
arrives in the emergency department. Her
history includes type 1 diabetes mellitus,
hypertension, and angina pectoris.
Assessment reveals pallor, diaphoresis,
headache, and intense hunger. A stat A.
blood glucose sample measures 42 B.
mg/dl, and the client is treated for an C.
acute hypoglycemic reaction. After D.
recovery, nurse Lily teaches the client to
treat hypoglycemia by ingesting:
A. 2 to 5 g of a simple carbohydrate.
B.  10 to 15 g of a simple carbohydrate. A.
C.  18 to 20 g of a simple carbohydrate. B.
D.  25 to 30 g of a simple carbohydrate. C.
2. A female adult client with a history of D.
chronic hyperparathyroidism admits to
being noncompliant. Based on initial
assessment findings, nurse Julia
formulates the nursing diagnosis of Risk
for injury. To complete the nursing
diagnosis statement for this client, which A.
“related-to” phrase should the nurse add? B.
C.
A. Related to bone demineralization resulting in
D.
pathologic fractures
B. Related to exhaustion secondary to an
accelerated metabolic rate
C. Related to edema and dry skin secondary to
fluid infiltration into the interstitial spaces
D. Related to tetany secondary to a decreased
serum calcium level
3. Nurse John is assigned to care for a
postoperative male client who has
diabetes mellitus. During the assessment
interview, the client reports that he’s A.
impotent and says he’s concerned about B.
C.
its effect on his marriage. In planning this
D.
client’s care, the most appropriate
intervention would be to:
A. Encourage the client to ask questions about
personal sexuality.
B. Provide time for privacy. A.
C. Provide support for the spouse or significant B.
other. C.
D. Suggest referral to a sex counselor or other D.
appropriate professional.
4. During a class on exercise for diabetic
clients, a female client asks the nurse
educator how often to exercise. The
nurse educator advises the clients to
exercise how often to meet the goals of
planned exercise?
At least once a week
At least three times a week
At least five times a week
Every day
5. Nurse Oliver should expect a client with
hypothyroidism to report which health
concerns?
Increased appetite and weight loss
Puffiness of the face and hands
Nervousness and tremors
Thyroid gland swelling
6. A female client with hypothyroidism
(myxedema) is receiving levothyroxine
(Synthroid), 25 mcg P.O. daily. Which
finding should nurse Hans recognize as
an adverse drug effect?
Dysuria
Leg cramps
Tachycardia
Blurred vision
7. A 67-year-old male client has been
complaining of sleeping more, increased
urination, anorexia, weakness, irritability,
depression, and bone pain that interferes
with her going outdoors. Based on these
assessment findings, nurse Richard
would suspect which of the following
disorders?
Diabetes mellitus
Diabetes insipidus
Hypoparathyroidism
Hyperparathyroidism
8. When caring for a male client with
diabetes insipidus, nurse Juliet expects to
administer:
vasopressin (Pitressin Synthetic).
furosemide (Lasix).
regular insulin.
10% dextrose.
 9. The nurse is aware that the following is
the most common cause of
hyperaldosteronism?
A. Excessive sodium intake
B. A pituitary adenoma
C. Deficient potassium intake
D.  An adrenal adenoma
10. A male client with type 1 diabetes
mellitus has a highly elevated
glycosylated hemoglobin (Hb) test result.
In discussing the result with the client,
nurse Sharmaine would be most accurate
in stating:
A. “The test needs to be repeated following a 12-
hour fast.”
B.  “It looks like you aren’t following the
prescribed diabetic diet.”
C.  “It tells us about your sugar control for the
last 3 months.”
D. “Your insulin regimen needs to be altered
significantly.”
11. Following a unilateral adrenalectomy,
nurse Betty would assess for
hyperkalemia shown by which of the
following?
A. Muscle weakness
B.  Tremors
C.  Diaphoresis
D. Constipation
12. Nurse Louie is developing a teaching
plan for a male client diagnosed with
diabetes insipidus. The nurse should
include information about which hormone
lacking in clients with diabetes insipidus?
A.  antidiuretic hormone (ADH).
B.  thyroid-stimulating hormone (TSH).
C.  follicle-stimulating hormone (FSH).
D. luteinizing hormone (LH).
13. Early this morning, a female client had
a subtotal thyroidectomy. During evening
rounds, nurse Tina assesses the client,
who now has nausea, a temperature of
105° F (40.5° C), tachycardia, and
extreme restlessness. What is the most
likely cause of these signs?
A. Diabetic ketoacidosis
B. Thyroid crisis
C.  Hypoglycemia
D.  Tetany
14. For a male client with hyperglycemia,
which assessment finding best supports a
nursing diagnosis of Deficient fluid
volume?
A.  Cool, clammy skin
B.  Distended neck veins
C. Increased urine osmolarity
D. Decreased serum sodium level
15. When assessing a male client with
pheochromocytoma, a tumor of the
adrenal medulla that secretes excessive
catecholamine, nurse April is most likely
to detect:
A. a blood pressure of 130/70 mm Hg.
B. a blood glucose level of 130 mg/dl.
C.  bradycardia.
D.  a blood pressure of 176/88 mm Hg.
16. A male client is admitted for treatment
of the syndrome of inappropriate
antidiuretic hormone (SIADH). Which
nursing intervention is appropriate?
A.  Infusing I.V. fluids rapidly as ordered
B.  Encouraging increased oral intake
C.  Restricting fluids
D.  Administering glucose-containing I.V. fluids
as ordered
17. A female client has a serum calcium
level of 7.2 mg/dl. During the physical
examination, nurse Noah expects to
assess:
A.  Trousseau’s sign.
B.  Homans’ sign.
C.  Hegar’s sign.
D.  Goodell’s sign.
18. Which outcome indicates that
treatment of a male client with diabetes
insipidus has been effective?
A.  Fluid intake is less than 2,500 ml/day.
B.  Urine output measures more than 200
ml/hour.
C.  Blood pressure is 90/50 mm Hg.
D. The heart rate is 126 beats/minute.
19. Jemma, who weighs 210 lb (95 kg)
and has been diagnosed with
hyperglycemia tells the nurse that her
husband sleeps in another room because
her snoring keeps him awake. The nurse
 notices that she has large hands and a
hoarse voice. Which of the following
would the nurse suspect as a possible
cause of the client’s hyperglycemia?
A. Acromegaly
B.  Type 1 diabetes mellitus
C.  Hypothyroidism
D.  Deficient growth hormone
20. Nurse Kate is providing dietary
instructions to a male client with
hypoglycemia. To control hypoglycemic
episodes, the nurse should recommend:
A.  Increasing saturated fat intake and fasting in
the afternoon.
B.  Increasing intake of vitamins B and D and
taking iron supplements.
C.  Eating a candy bar if light-headedness occurs.
D.  Consuming a low-carbohydrate, high-protein
diet and avoiding fasting.
21. An incoherent female client with a
history of hypothyroidism is brought to the
emergency department by the rescue
squad. Physical and laboratory findings
reveal hypothermia, hypoventilation,
respiratory acidosis, bradycardia,
hypotension, and nonpitting edema of the
face and pretibial area. Knowing that
these findings suggest severe
hypothyroidism, nurse Libby prepares to
take emergency action to prevent the
potential complication of:
A. Thyroid storm.
B. Cretinism.
C. myxedema coma.
D. Hashimoto’s thyroiditis.
22. A male client with type 1 diabetes
mellitus asks the nurse about taking an
oral antidiabetic agent. Nurse Jack
explains that these medications are only
effective if the client:
A. prefers to take insulin orally.
B. has type 2 diabetes.
C. has type 1 diabetes.
D. is pregnant and has type 2 diabetes.
23. When caring for a female client with a
history of hypoglycemia, nurse Ruby
should avoid administering a drug that
may potentiate hypoglycemia. Which drug
fits this description?
A. sulfisoxazole (Gantrisin)
B. mexiletine (Mexitil)
C. prednisone (Orasone)
D. lithium carbonate (Lithobid)
24. After taking glipizide (Glucotrol) for 9
months, a male client experiences
secondary failure. Which of the following
would the nurse expect the physician to
do?
A. Initiate insulin therapy.
B. Switch the client to a different oral
antidiabetic agent.
C. Prescribe an additional oral antidiabetic agent.
D. Restrict carbohydrate intake to less than 30%
of the total caloric intake.
25. During preoperative teaching for a
female client who will undergo subtotal
thyroidectomy, the nurse should include
which statement?
A. “The head of your bed must remain flat for 24
hours after surgery.”
B. “You should avoid deep breathing and
coughing after surgery.”
C.  “You won’t be able to swallow for the first
day or two.”
D.  “You must avoid hyperextending your neck
after surgery.”
Answers and Rationales
1. Answer B. To reverse hypoglycemia, the
American Diabetes Association recommends
ingesting 10 to 15 g of a simple carbohydrate,
such as three to five pieces of hard candy, two
to three packets of sugar (4 to 6 tsp), or 4 oz
of fruit juice. If necessary, this treatment can
be repeated in 15 minutes. Ingesting only 2 to
5 g of a simple carbohydrate may not raise the
blood glucose level sufficiently. Ingesting
more than 15 g may raise it above normal,
causing hyperglycemia.
2. Answer A. Poorly controlled
hyperparathyroidism may cause an elevated
serum calcium level. This, in turn, may
diminish calcium stores in the bone, causing
bone demineralization and setting the stage
for pathologic fractures and a risk for injury.
Hyperparathyroidism doesn’t accelerate the
metabolic rate. A decreased thyroid hormone
level, not an increased parathyroid hormone
level, may cause edema and dry skin
 secondary to fluid infiltration into the
interstitial spaces. Hyperparathyroidism
causes hypercalcemia, not hypocalcemia;
therefore, it isn’t associated with tetany.
3. Answer D. The nurse should refer this client
to a sex counselor or other professional.
Making appropriate referrals is a valid part of
planning the client’s care. The nurse doesn’t
normally provide sex counseling.
4. Answer B. Diabetic clients must exercise at
least three times a week to meet the goals of
planned exercise — lowering the blood
glucose level, reducing or maintaining the
proper weight, increasing the serum high-
density lipoprotein level, decreasing serum
triglyceride levels, reducing blood pressure,
and minimizing stress. Exercising once a
week wouldn’t achieve these goals.
Exercising more than three times a week,
although beneficial, would exceed the
minimum requirement.
5. Answer B. Hypothyroidism (myxedema)
causes facial puffiness, extremity edema, and
weight gain. Signs and symptoms of
hyperthyroidism (Graves’ disease) include an
increased appetite, weight loss, nervousness,
tremors, and thyroid gland enlargement
(goiter).
6. Answer C. Levothyroxine, a synthetic thyroid
hormone, is given to a client with
hypothyroidism to simulate the effects of
thyroxine. Adverse effects of this agent
include tachycardia. The other options aren’t
associated with levothyroxine.
7. Answer D. Hyperparathyroidism is most
common in older women and is characterized
by bone pain and weakness from excess
parathyroid hormone (PTH). Clients also
exhibit hypercaliuria-causing polyuria. While
clients with diabetes mellitus and diabetes
insipidus also have polyuria, they don’t have
bone pain and increased sleeping.
Hypoparathyroidism is characterized by
urinary frequency rather than polyuria.
8. Answer A. Because diabetes insipidus results
from decreased antidiuretic hormone
(vasopressin) production, the nurse should
expect to administer synthetic vasopressin for
hormone replacement therapy. Furosemide, a
diuretic, is contraindicated because a client
with diabetes insipidus experiences polyuria.
Insulin and dextrose are used to treat diabetes
mellitus and its complications, not diabetes
insipidus.
9. Answer D. An autonomous aldosterone-
producing adenoma is the most common
cause of hyperaldosteronism. Hyperplasia is
the second most frequent cause. Aldosterone
secretion is independent of sodium and
potassium intake as well as of pituitary
stimulation.
10.Answer C. The glycosylated Hb test provides
an objective measure of glycemic control over
a 3-month period. The test helps identify
trends or practices that impair glycemic
control, and it doesn’t require a fasting period
before blood is drawn. The nurse can’t
conclude that the result occurs from poor
dietary management or inadequate insulin
coverage.
11.Answer A. Muscle weakness, bradycardia,
nausea, diarrhea, and paresthesia of the hands,
feet, tongue, and face are findings associated
with hyperkalemia, which is transient and
occurs from transient hypoaldosteronism
when the adenoma is removed. Tremors,
diaphoresis, and constipation aren’t seen in
hyperkalemia.
12.Answer A. ADH is the hormone clients with
diabetes insipidus lack. The client’s TSH,
FSH, and LH levels won’t be affected.
13.Answer B. Thyroid crisis usually occurs in
the first 12 hours after thyroidectomy and
causes exaggerated signs of hyperthyroidism,
such as high fever, tachycardia, and extreme
restlessness. Diabetic ketoacidosis is more
likely to produce polyuria, polydipsia, and
polyphagia; hypoglycemia, to produce
weakness, tremors, profuse perspiration, and
hunger. Tetany typically causes
uncontrollable muscle spasms, stridor,
cyanosis, and possibly asphyxia.
14.Answer C. In hyperglycemia, urine
osmolarity (the measurement of dissolved
particles in the urine) increases as glucose
particles move into the urine. The client
experiences glucosuria and polyuria, losing
body fluids and experiencing fluid volume
deficit. Cool, clammy skin; distended neck
veins; and a decreased serum sodium level are
signs of fluid volume excess, the opposite
imbalance.
15.Answer D. Pheochromocytoma, a tumor of
the adrenal medulla that secretes excessive
catecholamine, causes hypertension,
tachycardia, hyperglycemia,
hypermetabolism, and weight loss. It isn’t
associated with the other options.
16.Answer C. To reduce water retention in a
client with the SIADH, the nurse should
restrict fluids. Administering fluids by any
route would further increase the client’s
already heightened fluid load.
17.Answer A. This client’s serum calcium level
indicates hypocalcemia, an electrolyte
imbalance that causes Trousseau’s sign
(carpopedal spasm induced by inflating the
blood pressure cuff above systolic pressure).
Homans’ sign (pain on dorsiflexion of the
foot) indicates deep vein thrombosis. Hegar’s
sign (softening of the uterine isthmus) and
Goodell’s sign (cervical softening) are
probable signs of pregnancy.
18.Answer A. Diabetes insipidus is characterized
by polyuria (up to 8 L/day), constant thirst,
and an unusually high oral intake of fluids.
Treatment with the appropriate drug should
decrease both oral fluid intake and urine
output. A urine output of 200 ml/hour
indicates continuing polyuria. A blood
pressure of 90/50 mm Hg and a heart rate of
126 beats/minute indicate compensation for
the continued fluid deficit, suggesting that
treatment hasn’t been effective.
19.Answer A. Acromegaly, which is caused by a
pituitary tumor that releases excessive growth
hormone, is associated with hyperglycemia,
hypertension, diaphoresis, peripheral
neuropathy, and joint pain. Enlarged hands
and feet are related to lateral bone growth,
which is seen in adults with this disorder. The
accompanying soft tissue swelling causes
hoarseness and often sleep apnea. Type 1
diabetes is usually seen in children, and newly
diagnosed persons are usually very ill and
thin. Hypothyroidism isn’t associated with
hyperglycemia, nor is growth hormone
deficiency.
20.Answer D. To control hypoglycemic
episodes, the nurse should instruct the client
to consume a low-carbohydrate, high-protein
diet, avoid fasting, and avoid simple sugars.
Increasing saturated fat intake and increasing
vitamin supplementation wouldn’t help
control hypoglycemia.
21.Answer C. Severe hypothyroidism may result
in myxedema coma, in which a drastic drop in
the metabolic rate causes decreased vital
signs, hypoventilation (possibly leading to
respiratory acidosis), and nonpitting edema.
Thyroid storm is an acute complication of
hyperthyroidism. Cretinism is a form of
hypothyroidism that occurs in infants.
Hashimoto’s thyroiditis is a common chronic
inflammatory disease of the thyroid gland in
which autoimmune factors play a prominent
role.
22.Answer B. Oral antidiabetic agents are only
effective in adult clients with type 2 diabetes.
Oral antidiabetic agents aren’t effective in
type 1 diabetes. Pregnant and lactating women
aren’t prescribed oral antidiabetic agents
because the effect on the fetus is uncertain.
23.Answer A. Sulfisoxazole and other
sulfonamides are chemically related to oral
antidiabetic agents and may precipitate
hypoglycemia. Mexiletine, an antiarrhythmic,
is used to treat refractory ventricular
arrhythmias; it doesn’t cause hypoglycemia.
Prednisone, a corticosteroid, is associated
with hyperglycemia. Lithium may cause
transient hyperglycemia, not hypoglycemia.
24.Answer B. Many clients (25% to 60%) with
secondary failure respond to a different oral
antidiabetic agent. Therefore, it wouldn’t be
appropriate to initiate insulin therapy at this
time. However, if a new oral antidiabetic
agent is unsuccessful in keeping glucose
levels at an acceptable level, insulin may be
used in addition to the antidiabetic agent.
25.Answer D. To prevent undue pressure on the
surgical incision after subtotal thyroidectomy,
the nurse should advise the client to avoid
hyperextending the neck. The client may
elevate the head of the bed as desired and
should perform deep breathing and coughing
to help prevent pneumonia. Subtotal
thyroidectomy doesn’t affect swallowing.
 NCLEX Practice Exam for Endocrine Disorder 2
1. Nurse Ronn is assessing a client with
possible Cushing’s syndrome. In a client
with Cushing’s syndrome, the nurse
would expect to find:
A. Hypotension.
B. Thick, coarse skin.
C. Deposits of adipose tissue in the trunk and
dorsocervical area.
D.  Weight gain in arms and legs.
2. A male client with primary diabetes
insipidus is ready for discharge on
desmopressin (DDAVP). Which
instruction should nurse Lina provide?
A. “Administer desmopressin while the
suspension is cold.”
B.  “Your condition isn’t chronic, so you won’t
need to wear a medical identification
bracelet.”
C. “You may not be able to use desmopressin
nasally if you have nasal discharge or
blockage.”
D. “You won’t need to monitor your fluid intake
and output after you start taking
desmopressin.”
3. Nurse Wayne is aware that a positive
Chvostek’s sign indicate?
A. Hypocalcemia
B. Hyponatremia
C. Hypokalemia
D. Hypermagnesemia
4. In a 29-year-old female client who is
being successfully treated for Cushing’s
syndrome, nurse Lyzette would expect a
decline in:
A. Serum glucose level.
B. Hair loss.
C. Bone mineralization.
D. Menstrual flow.
5. A male client has recently undergone
surgical removal of a pituitary tumor. Dr.
Wong prescribes corticotropin (Acthar),
20 units I.M. q.i.d. as a replacement
therapy. What is the mechanism of action
of corticotropin?
A. It decreases cyclic adenosine monophosphate
(cAMP) production and affects the metabolic
rate of target organs.
B. It interacts with plasma membrane receptors
to inhibit enzymatic actions.
C. It interacts with plasma membrane receptors
to produce enzymatic actions that affect
protein, fat, and carbohydrate metabolism.
D. It regulates the threshold for water resorption
in the kidneys.
6. Capillary glucose monitoring is being
performed every 4 hours for a female
client diagnosed with diabetic
ketoacidosis. Insulin is administered using
a scale of regular insulin according to
glucose results. At 2 p.m., the client has a
capillary glucose level of 250 mg/dl for
which he receives 8 U of regular insulin.
Nurse Vince should expect the dose’s:
A. Onset to be at 2 p.m. and its peak to be at 3
p.m.
B. Onset to be at 2:15 p.m. and its peak to be at 3
p.m.
C. Onset to be at 2:30 p.m. and its peak to be at 4
p.m.
D. Onset to be at 4 p.m. and its peak to be at 6
p.m.
7. A female client with Cushing’s
syndrome is admitted to the medical-
surgical unit. During the admission
assessment, nurse Tyzz notes that the
client is agitated and irritable, has poor
memory, reports loss of appetite, and
appears disheveled. These findings are
consistent with which problem?
A. Depression
B. Neuropathy
C. Hypoglycemia
D. Hyperthyroidism
8. Nurse Ruth is assessing a client after a
thyroidectomy. The assessment reveals
muscle twitching and tingling, along with
numbness in the fingers, toes, and mouth
area. The nurse should suspect which
complication?
A. Tetany
B. Hemorrhage
C. Thyroid storm
D. Laryngeal nerve damage
9. After undergoing a subtotal
thyroidectomy, a female client develops
hypothyroidism. Dr. Smith prescribes
 levothyroxine (Levothroid), 25 mcg P.O. Pauleen would be aware of the client’s
daily. For which condition is levothyroxine need for additional teaching when the
the preferred agent? client states:
A. Primary hypothyroidism A. “If I have hypoglycemia, I should eat some
B. Graves’ disease sugar, not dextrose.”
C.  Thyrotoxicosis B. “The drug makes my pancreas release more
D. Euthyroidism insulin.”
10. Which of these signs suggests that a C.  “I should never take insulin while I’m taking
male client with the syndrome of this drug.”
D.  “It’s best if I take the drug with the first bite
inappropriate antidiuretic hormone
of a meal.”
(SIADH) secretion is experiencing
15. A female client whose physical
complications?
findings suggest a hyperpituitary condition
A. Tetanic contractions undergoes an extensive diagnostic
B. Neck vein distention workup. Test results reveal a pituitary
C. Weight loss tumor, which necessitates a
D. Polyuria
transphenoidal hypophysectomy. The
11. A female client with a history of evening before the surgery, nurse Jacob
pheochromocytoma is admitted to the reviews preoperative and postoperative
hospital in an acute hypertensive crisis. instructions given to the client earlier.
To reverse hypertensive crisis caused by Which postoperative instruction should
pheochromocytoma, nurse Lyka expects the nurse emphasize?
to administer:
A. “You must lie flat for 24 hours after surgery.”
A. phentolamine (Regitine). B. “You must avoid coughing, sneezing, and
B. methyldopa (Aldomet). blowing your nose.”
C. mannitol (Osmitrol). C. “You must restrict your fluid intake.”
D. felodipine (Plendil). D.  “You must report ringing in your ears
12. A male client with a history of immediately.”
hypertension is diagnosed with primary 16. Dr. Kennedy prescribes glipizide
hyperaldosteronism. This diagnosis (Glucotrol), an oral antidiabetic agent, for
indicates that the client’s hypertension is a male client with type 2 diabetes mellitus
caused by excessive hormone secretion who has been having trouble controlling
from which of the following glands? the blood glucose level through diet and
exercise. Which medication instruction
A. Adrenal cortex
B. Pancreas should the nurse provide?
C. Adrenal medulla A. “Be sure to take glipizide 30 minutes before
D. Parathyroid
meals.”
13. Nurse Troy is aware that the most B. “Glipizide may cause a low serum sodium
appropriate for a client with Addison’s level, so make sure you have your sodium
disease? level checked monthly.”
C. “You won’t need to check your blood glucose
A. Risk for infection level after you start taking glipizide.”
B. Excessive fluid volume D. “Take glipizide after a meal to prevent
C. Urinary retention heartburn.”
D. Hypothermia 17. For a diabetic male client with a foot
14. Acarbose (Precose), an alpha- ulcer, the physician orders bed rest, a
glucosidase inhibitor, is prescribed for a wet-to-dry dressing change every shift,
female client with type 2 diabetes and blood glucose monitoring before
mellitus. During discharge planning, nurse
 meals and bedtime. Why are wet-to-dry
dressings used for this client?
A. They contain exudate and provide a moist
wound environment.
B. They protect the wound from mechanical
trauma and promote healing.
C. They debride the wound and promote healing
by secondary intention.
D. They prevent the entrance of microorganisms
and minimize wound discomfort.
18. When instructing the female client
diagnosed with hyperparathyroidism
about diet, nurse Gina should stress the
importance of which of the following?
A. Restricting fluids
B. Restricting sodium
C. Forcing fluids
D. Restricting potassium
19. Which nursing diagnosis takes
highest priority for a female client with
hyperthyroidism?
A. Risk for imbalanced nutrition: More than
body requirements related to thyroid hormone
excess
B. Risk for impaired skin integrity related to
edema, skin fragility, and poor wound healing
C. Body image disturbance related to weight gain
and edema
D. Imbalanced nutrition: Less than body
requirements related to thyroid hormone
excess
20. A male client with a tentative
diagnosis of hyperosmolar hyperglycemic
nonketotic syndrome (HHNS) has a
history of type 2 diabetes that is being
controlled with an oral diabetic agent,
tolazamide (Tolinase). Which of the
following is the most important laboratory
test for confirming this disorder?
A. Serum potassium level
B. Serum sodium level
C. Arterial blood gas (ABG) values
D. Serum osmolarity
21. A male client has just been diagnosed
with type 1 diabetes mellitus. When
teaching the client and family how diet
and exercise affect insulin requirements,
Nurse Joy should include which
guideline?
A. “You’ll need more insulin when you exercise
or increase your food intake.”
B. “You’ll need less insulin when you exercise
or reduce your food intake.”
C. “You’ll need less insulin when you increase
your food intake.”
D. “You’ll need more insulin when you exercise
or decrease your food intake.”
22. Nurse Noemi administers glucagon to
her diabetic client, then monitors the
client for adverse drug reactions and
interactions. Which type of drug interacts
adversely with glucagon?
A. Oral anticoagulants
B. Anabolic steroids
C. Beta-adrenergic blockers
D. Thiazide diuretics
23. Which instruction about insulin
administration should nurse Kate give to a
client?
A. “Always follow the same order when drawing
the different insulins into the syringe.”
B. “Shake the vials before withdrawing the
insulin.”
C. “Store unopened vials of insulin in the freezer
at temperatures well below freezing.”
D. “Discard the intermediate-acting insulin if it
appears cloudy.”
24. Nurse Perry is caring for a female
client with type 1 diabetes mellitus who
exhibits confusion, light-headedness, and
aberrant behavior. The client is still
conscious. The nurse should first
administer:
A. I.M. or subcutaneous glucagon.
B. I.V. bolus of dextrose 50%.
C. 15 to 20 g of a fast-acting carbohydrate such
as orange juice.
D. 10 U of fast-acting insulin.
25. For the first 72 hours after
thyroidectomy surgery, nurse Jamie
would assess the female client for
Chvostek’s sign and Trousseau’s sign
because they indicate which of the
following?
A. Hypocalcemia
B. Hypercalcemia
C. Hypokalemia
D. Hyperkalemia
 Answers and Rationales
1. Answer C. Because of changes in fat
distribution, adipose tissue accumulates in the
trunk, face (moonface), and dorsocervical
areas (buffalo hump). Hypertension is caused
by fluid retention. Skin becomes thin and
bruises easily because of a loss of collagen.
Muscle wasting causes muscle atrophy and
thin extremities.
2. Answer C. Desmopressin may not be
absorbed if the intranasal route is
compromised. Although diabetes insipidus is
treatable, the client should wear medical
identification and carry medication at all times
to alert medical personnel in an emergency
and ensure proper treatment. The client must
continue to monitor fluid intake and output
and receive adequate fluid replacement.
3. Answer A. Chvostek’s sign is elicited by
tapping the client’s face lightly over the facial
nerve, just below the temple. If the client’s
facial muscles twitch, it indicates
hypocalcemia. Hyponatremia is indicated by
weight loss, abdominal cramping, muscle
weakness, headache, and postural
hypotension. Hypokalemia causes paralytic
ileus and muscle weakness. Clients with
hypermagnesemia exhibit a loss of deep
tendon reflexes, coma, or cardiac arrest.
4. Answer A. Hyperglycemia, which develops
from glucocorticoid excess, is a manifestation
of Cushing’s syndrome. With successful
treatment of the disorder, serum glucose
levels decline. Hirsutism is common in
Cushing’s syndrome; therefore, with
successful treatment, abnormal hair growth
also declines. Osteoporosis occurs in
Cushing’s syndrome; therefore, with
successful treatment, bone mineralization
increases. Amenorrhea develops in Cushing’s
syndrome. With successful treatment, the
client experiences a return of menstrual flow,
not a decline in it.
5. Answer C. Corticotropin interacts with
plasma membrane receptors to produce
enzymatic actions that affect protein, fat, and
carbohydrate metabolism. It doesn’t decrease
cAMP production. The posterior pituitary
hormone, antidiuretic hormone, regulates the
threshold for water resorption in the kidneys.
6. Answer C. Regular insulin, which is a short-
acting insulin, has an onset of 15 to 30
minutes and a peak of 2 to 4 hours. Because
the nurse gave the insulin at 2 p.m., the
expected onset would be from 2:15 p.m. to
2:30 p.m. and the peak from 4 p.m. to 6 p.m.
7. Answer A. Agitation, irritability, poor
memory, loss of appetite, and neglect of one’s
appearance may signal depression, which is
common in clients with Cushing’s syndrome.
Neuropathy affects clients with diabetes
mellitus — not Cushing’s syndrome.
Although hypoglycemia can cause irritability,
it also produces increased appetite, rather than
loss of appetite. Hyperthyroidism typically
causes such signs as goiter, nervousness, heat
intolerance, and weight loss despite increased
appetite.
8. Answer A. Tetany may result if the
parathyroid glands are excised or damaged
during thyroid surgery. Hemorrhage is a
potential complication after thyroid surgery
but is characterized by tachycardia,
hypotension, frequent swallowing, feelings of
fullness at the incision site, choking, and
bleeding. Thyroid storm is another term for
severe hyperthyroidism — not a complication
of thyroidectomy. Laryngeal nerve damage
may occur postoperatively, but its signs
include a hoarse voice and, possibly, acute
airway obstruction.
9. Answer A. Levothyroxine is the preferred
agent to treat primary hypothyroidism and
cretinism, although it also may be used to
treat secondary hypothyroidism. It is
contraindicated in Graves’ disease and
thyrotoxicosis because these conditions are
forms of hyperthyroidism. Euthyroidism, a
term used to describe normal thyroid function,
wouldn’t require any thyroid preparation.
10. Answer B. SIADH secretion causes
antidiuretic hormone overproduction, which
leads to fluid retention. Severe SIADH can
cause such complications as vascular fluid
overload, signaled by neck vein distention.
This syndrome isn’t associated with tetanic
contractions. It may cause weight gain and
fluid retention (secondary to oliguria).
11.Answer A. Pheochromocytoma causes
excessive production of epinephrine and
norepinephrine, natural catecholamines that
raise the blood pressure. Phentolamine, an
alpha-adrenergic blocking agent given by I.V.
bolus or drip, antagonizes the body’s response
to circulating epinephrine and norepinephrine,
reducing blood pressure quickly and
effectively. Although methyldopa is an
antihypertensive agent available in parenteral
form, it isn’t effective in treating hypertensive
 emergencies. Mannitol, a diuretic, isn’t used
to treat hypertensive emergencies. Felodipine,
an antihypertensive agent, is available only in
extended-release tablets and therefore doesn’t
reduce blood pressure quickly enough to
correct hypertensive crisis.
12.Answer A. Excessive secretion of aldosterone
in the adrenal cortex is responsible for the
client’s hypertension. This hormone acts on
the renal tubule, where it promotes
reabsorption of sodium and excretion of
potassium and hydrogen ions. The pancreas
mainly secretes hormones involved in fuel
metabolism. The adrenal medulla secretes the
catecholamines — epinephrine and
norepinephrine. The parathyroids secrete
parathyroid hormone.
13.Answer A. Addison’s disease decreases the
production of all adrenal hormones,
compromising the body’s normal stress
response and increasing the risk of infection.
Other appropriate nursing diagnoses for a
client with Addison’s disease include
Deficient fluid volume and Hyperthermia.
Urinary retention isn’t appropriate because
Addison’s disease causes polyuria.
14.Answer A. Acarbose delays glucose
absorption, so the client should take an oral
form of dextrose rather than a product
containing table sugar when treating
hypoglycemia. The alpha-glucosidase
inhibitors work by delaying the carbohydrate
digestion and glucose absorption. It’s safe to
be on a regimen that includes insulin and an
alpha-glucosidase inhibitor. The client should
take the drug at the start of a meal, not 30
minutes to an hour before.
15.Answer B. After a transsphenoidal
hypophysectomy, the client must refrain from
coughing, sneezing, and blowing the nose for
several days to avoid disturbing the surgical
graft used to close the wound. The head of the
bed must be elevated, not kept flat, to prevent
tension or pressure on the suture line. Within
24 hours after a hypophysectomy, transient
diabetes insipidus commonly occurs; this calls
for increased, not restricted, fluid intake.
Visual, not auditory, changes are a potential
complication of hypophysectomy.
16.Answer A. The client should take glipizide
twice a day, 30 minutes before a meal,
because food decreases its absorption. The
drug doesn’t cause hyponatremia and
therefore doesn’t necessitate monthly serum
sodium measurement. The client must
continue to monitor the blood glucose level
during glipizide therapy.
17.Answer C. For this client, wet-to-dry
dressings are most appropriate because they
clean the foot ulcer by debriding exudate and
necrotic tissue, thus promoting healing by
secondary intention. Moist, transparent
dressings contain exudate and provide a moist
wound environment. Hydrocolloid dressings
prevent the entrance of microorganisms and
minimize wound discomfort. Dry sterile
dressings protect the wound from mechanical
trauma and promote healing.
18.Answer C. The client should be encouraged
to force fluids to prevent renal calculi
formation. Sodium should be encouraged to
replace losses in urine. Restricting potassium
isn’t necessary in hyperparathyroidism.
19.Answer D. In the client with hyperthyroidism,
excessive thyroid hormone production leads
to hypermetabolism and increased nutrient
metabolism. These conditions may result in a
negative nitrogen balance, increased protein
synthesis and breakdown, decreased glucose
tolerance, and fat mobilization and depletion.
This puts the client at risk for marked nutrient
and calorie deficiency, making Imbalanced
nutrition: Less than body requirements the
most important nursing diagnosis. Options B
and C may be appropriate for a client with
hypothyroidism, which slows the metabolic
rate.
20.Answer D. Serum osmolarity is the most
important test for confirming HHNS; it’s also
used to guide treatment strategies and
determine evaluation criteria. A client with
HHNS typically has a serum osmolarity of
more than 350 mOsm/L. Serum potassium,
serum sodium, and ABG values are also
measured, but they aren’t as important as
serum osmolarity for confirming a diagnosis
of HHNS. A client with HHNS typically has
hypernatremia and osmotic diuresis. ABG
values reveal acidosis, and the potassium level
is variable.
21.Answer B. Exercise, reduced food intake,
hypothyroidism, and certain medications
decrease the insulin requirements. Growth,
pregnancy, greater food intake, stress,
surgery, infection, illness, increased insulin
antibodies, and certain medications increase
the insulin requirements.
22.Answer A. As a normal body protein,
glucagon only interacts adversely with oral
anticoagulants, increasing the anticoagulant
 effects. It doesn’t interact adversely with
anabolic steroids, beta-adrenergic blockers, or
thiazide diuretics.
23.Answer A. The client should be instructed
always to follow the same order when
drawing the different insulins into the syringe.
Insulin should never be shaken because the
resulting froth prevents withdrawal of an
accurate dose and may damage the insulin
protein molecules. Insulin also should never
be frozen because the insulin protein
molecules may be damaged. Intermediate-
acting insulin is normally cloudy.
24.Answer C. This client is having a
hypoglycemic episode. Because the client is
conscious, the nurse should first administer a
fast-acting carbohydrate, such as orange juice,
hard candy, or honey. If the client has lost
consciousness, the nurse should administer
either I.M. or subcutaneous glucagon or an
I.V. bolus of dextrose 50%. The nurse
shouldn’t administer insulin to a client who’s
hypoglycemic; this action will further
compromise the client’s condition.
25.Answer A. The client who has undergone a
thyroidectomy is at risk for developing
hypocalcemia from inadvertent removal or
damage to the parathyroid gland. The client
with hypocalcemia will exhibit a positive
Chvostek’s sign (facial muscle contraction
when the facial nerve in front of the ear is
tapped) and a positive Trousseau’s sign
(carpal spasm when a blood pressure cuff is
inflated for a few minutes). These signs aren’t
present with hypercalcemia, hypokalemia, or
hyperkalemia.
 NCLEX Practice Exam for F&E & Homeostasis 1
1. Patient X is diagnosed
with constipation. As a knowledgeable
nurse, which nursing intervention is
appropriate for maintaining normal bowel
function?
A. Assessing dietary intake
B. Decreasing fluid intake
C. Providing limited physical activity
D. Turning, coughing, and deep breathing
2. A 12-year-old boy was admitted in the
hospital two days ago due to
hyperthermia. His attending nurse,
Dennis, is quite unsure about his plan of
care. Which of the following nursing
intervention should be included in the
care of plan for the client?
A. Room temperature reduction
B. Fluid restriction of 2,000 ml/day
C. Axillary temperature measurements every 4
hours
D. Antiemetic agent administration
3. Tom is ready to be discharged from the
medical-surgical unit after 5 days of
hospitalization. Which client statement
indicates to the nurse that Tom
understands the discharge teaching about
cellular injury?
A. “I do not have to see my doctor unless i have
problems.”
B. “I can stop taking my antibiotics once I am
feeling better.”
C. “If I have redness, drainage, or fever, I should
call my healthcare provider.”
D. “I can return to my normal activities as soon
as I go home.”
4. Nurse Katee is caring for Adam, a 22-
year-old client, in a long-term facility.
Which nursing intervention would be
appropriate when identifying nursing
interventions aimed at promoting and
preventing contractures? Select all that
apply.
A. Clustering activities to allow uninterrupted
periods of rest
B. Maintaining correct body alignment at all
times
C. Monitoring intake and output, using a
urometer if necessary
D. Using a footboard or pillows to keep feet in
correct position
E. Performing active and passive range-of-
motion exercises
F. Weighing the client daily at the same time and
in the same clothes
5. A 36-year-old male client is about to be
discharged from the the hospital after 5
days due to surgery. Which intervention
should be included in the home health
care nurse’s instructions about measures
to prevent constipation?
A. Discouraging the client from eating large
amounts of roughage-containing foods in the
diet.
B. Encouraging the client to use laxatives
routinely to ensure adequate bowel
elimination.
C. Instructing the client to establish a bowel
evacuation schedule that changes every day.
D. Instructing the client to fill a 2-L bottle with
water every night and drink it the next day.
6. Mr. McPartlin suffered abrasions and
lacerations after a vehicular accident. He
was hospitalized and was treated for a
couple of weeks. When planning care for
a client with cellular injury, the nurse
should consider which scientific rationale?
A. Nutritional needs remain unchanged for the
well-nourished adult.
B. Age is an insignificant factor in cellular
repair.
C. The presence of infection may slow the
healing process.
D. Tissue with inadequate blood supply may heal
faster.
7. A 22-year-old lady is displaying facial
grimaces during her treatment in the
hospital due to burn trauma. Which
nursing intervention should be included
for reducing pain due to cellular injury?
A. Administering anti-inflammatory agents as
prescribed
B. Elevating the injured area to decrease venous
return to the heart
C. Keeping the skin clean and dry
D. Applying warm packs initially to reduce
edema
8. Lisa, a client with altered urinary
function, is under the care of nurse Tine.
 Which intervention is appropriate to
include when developing a plan of care
for Lisa who is experiencing urinary
dribbling?
A. Inserting an indwelling Foley catheter
B. Having the client perform Kegel exercises
C. Keeping the skin clean and dry
D. Using pads or diapers on the client
9. Jeron is admitted in the hospital due to
bacterial pneumonia. He is febrile,
diaphoretic, and has shortness of breath
and asthma. Which goal is the most
important for the client?
A. Prevention of fluid volume excess
B. Maintenance of adequate oxygenation
C. Education about infection prevention
D. Pain reduction
10. Mang Rogelio, a 32-year-old patient,
is about to be discharged from the acute
care setting. Which nursing intervention is
the most important to include in the plan
of care?
A. Stress-reduction techniques
B. Home environment evaluation
C. Skin-care measures
D. Participation in activities of daily living
11. Mrs. dela Riva is in her first trimester
of pregnancy. She has been lying all day
because her OB-GYN requested her to
have a complete bed rest. Which nursing
intervention is appropriate when
addressing the client’s need to maintain
skin integrity?
A. Monitoring intake and output accurately
B. Instructing the client to cough and deep-
breathe every 2 hours
C. Keeping the linens dry and wrinkle free
D. Using a foot board to maintain correct
anatomic position
12. Maya, who is admitted in a hospital, is
scheduled to have her general checkup
and physical assessment. Nurse Timothy
observed a reddened area over her left
hip. Which should the nurse do first?
A. Massage the reddened are for a few minutes
B. Notify the physician immediately
C. Arrange for a pressure-relieving device
D. Turn the client to the right side for 2 hours
13. Pierro was noted to be displaying
facial grimaces after nurse Kara assessed
his complaints of pain rated as 8 on a
scale of 1 (no pain) 10 10 (worst pain).
Which intervention should the nurse do?
A. Administering the client’s ordered pain
medication immediately
B. Using guided imagery instead of
administering pain medication
C. Using therapeutic conversation to try to
discourage pain medication
D. Attempting to rule out complications before
administering pain medication
14. Nurse Marthia is teaching her
students about bacterial control. Which
intervention is the most important factor in
preventing the spread of microorganism?
A. Maintenance of asepsis with indwelling
catheter insertion
B. Use of masks, gowns, and gloves when caring
for clients with infection
C. Correct handwashing technique
D. Cleanup of blood spills with sodium
hydrochloride
15. A patient with tented skin turgor, dry
mucous membranes, and decreased
urinary output is under nurse Mark’s care.
Which nursing intervention should be
included the care plan of Mark for his
patient?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the
day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein
levels
16. Khaleesi is admitted in the hospital
due to having lower than normal
potassium level in her bloodstream. Her
medical history reveals vomiting and
diarrhea prior to hospitalization. Which
foods should the nurse instruct the client
to increase?
A. Whole grains and nuts
B. Milk products and green, leafy vegetables
C. Pork products and canned vegetables
D. Orange juice and bananas
 17. Mary Jean, a first year nursing
student, was rushed to the clinic
department due to hyperventilation.
Which nursing intervention is the most
appropriate for the client who is
subsequently developing respiratory
alkalosis?
A. Administering sodium chloride I.V.
B. Encouraging slow, deep breaths
C. Preparing to administer sodium bicarbonate
D. Administer low-flow oxygen therapy
18. Nurse John Joseph is totaling the
intake and output for Elena Reyes, a
client diagnosed with septicemia who is
on a clear liquid diet. The client intakes 8
oz of apple juice, 850 ml of water, 2 cups
of beef broth, and 900 ml of half-normal
saline solution and outputs 1,500 ml of
urine during the shift. How many milliliters
should the nurse document as the client’s
intake.
A. 2,230
B. 2,740
C. 2,470
D. 2,320
19. Marie Joy’s lab test revealed that her
serum calcium is 2.5 mEq/L. Which
assessment data does the nurse
document when a client diagnosed with
hypocalcemia develops a carpopedal
spasm after the blood-pressure cuff is
inflated?
A. Positive Trousseau’s sign
B. Positive Chvostek’s sign
C. Tetany
D. Paresthesia
20. Lab tests revealed that patient Z’s
[Na+] is 170 mEq/L. Which clinical
manifestation would nurse Natty expect to
assess?
A. Tented skin turgor and thirst
B. Muscle twitching and tetany
C. Fruity breath and Kussmaul’s respirations
D. Muscle weakness and paresthesia
21. Mang Teban has a history of chronic
obstructive pulmonary disease and has
the following arterial blood gas results:
partial pressure of oxygen (PO2), 55 mm
Hg, and partial pressure of carbon dioxide
(PCO2), 60 mm Hg. When attempting to
improve the client’s blood gas values
through improved ventilation and oxygen
therapy, which is the client’s primary
stimulus for breathing?
A. High PCO2
B. Low PO2
C. Normal pH
D. Normal bicarbonate (HCO3)
22. A client with very dry mouth, skin and
mucous membranes is diagnosed of
having dehydration. Which intervention
should the nurse perform when caring for
a client diagnosed with fluid volume
deficit?
A. Assessing urinary intake and output
B. Obtaining the client’s weight weekly at
different times of the day
C. Monitoring arterial blood gas (ABG) results
D. Maintaining I.V. therapy at the keep-vein-
open rate
23. Which client situation requires the
nurse to discuss the importance of
avoiding foods high in potassium?
A. 14-year-old Elena who is taking diuretics
B. 16-year-old John Joseph with ileostomy
C. 16-year-old Gabriel with metabolic acidosis
D. 18-year-old Albert who has renal disease
24. Genevieve is diagnosed with
hypomagnesemia, which nursing
intervention would be appropriate?
A. Instituting seizure precaution to prevent injury
B. Instructing the client on the importance of
preventing infection
C. Avoiding the use of tight tourniquet when
drawing blood
D. Teaching the client the importance of early
ambulation
25. Which electrolyte would the nurse
identify as the major electrolyte
responsible for determining the
concentration of the extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium
 26. Jon has a potassium level of 6.5 A. high
mEq/L, which medication would nurse B. low
C. within normal range
Wilma anticipate?
D. high normal
A. Potassium supplements 32. Which of the following conditions is
B. Kayexalate associated with elevated serum chloride
C. Calcium gluconate levels?
D. Sodium tablets
27. Which clinical manifestation would A. cystitis
lead the nurse to suspect that a client is B. diabetes
C. eclampsia
experiencing hypermagnesemia?
D. hypertension
A. Muscle pain and acute rhabdomyolysis 33. In the extracellular fluid, chloride is a
B. Hot, flushed skin and diaphoresis major:
C. Soft-tissue calcification and hyperreflexia
D. Increased respiratory rate and depth A. compound
28. Joshua is receiving furosemide and B. ion
C. anion
Digoxin, which laboratory data would be
D. cation
the most important to assess in planning
34. Nursing intervention for the patient
the care for the client?
with hyperphosphatemia include
A. Sodium level encouraging intake of:
B. Magnesium level
C. Potassium level A. amphogel
D. Calcium level B. Fleets phospho-soda
C. milk
29. Mr. Salcedo has the following arterial
D. vitamin D
blood gas (ABG) values: pH of 7.34,
35. Etiologies associated with
partial pressure of arterial oxygen of 80
hypocalcemia may include all of the
mm Hg, partial pressure of arterial carbon
following except:
dioxide of 49 mm Hg, and a bicarbonate
level of 24 mEq/L. Based on these A. renal failure
results, which intervention should the B. inadequate intake calcium
nurse implement? C. metastatic bone lesions
D. vitamin D deficiency
A. Instructing the client to breathe slowly into a 36. Which of the following findings would
paper bag the nurse expect to asses in
B. Administering low-flow oxygen hypercalcemia?
C. Encouraging the client to cough and deep
breathe A. prolonged QRS complex
D. Nothing, because these ABG values are B. tetany
within normal limits. C. petechiae
30. A client is diagnosed with metabolic D. urinary calculi
acidosis, which would the nurse expect 37. Which of the following is not an
the health care provider to order? appropriate nursing intervention for a
patient with hypercalcemia?
A. Potassium
B. Sodium bicarbonate A. administering calcitonin
C. Serum sodium level B. administering calcium gluconate
D. Bronchodilator C. administering loop diuretics
31. Lee Angela’s lab test just revealed D. encouraging ambulation
that her chloride level is 96 mEq/L. As a 38. A patient in which of the following
nurse, you would interpret this serum disorders is at high risk to develop
chloride level as: hypermagnesemia?
A. insulin shock 45. When assessing a patient for signs of
B. hyperadrenalism fluid overload, the nurse would expect to
C. nausea and vomiting
observe:
D. renal failure
39. Nursing interventions for a patient A. bounding pulse
with hypermagnesemia  include B. flat neck veins
administering calcium gluconate to: C. poor skin turgor
D. vesicular
A. increase calcium levels 46. The physician has ordered IV
B. antagonize the cardiac effects of magnesium replacement of potassium for a patient
C. lower calcium levels
with severe hypokalemia. The nurse
D. lower magnesium levels
would administer this:
40. For a patient with hypomagnesemia,
which of the following medications may A. by rapid bolus
become toxic? B. diluted in 100 cc over 1 hour
C. diluted in 10 cc over 10 minutes
A. Lasix D. IV push
B. Digoxin 47. Which of the following findings would
C. calcium gluconate
the nurse exp[ect to assess in a patient
D. CAPD
with hypokalemia?
41. Which of the following is the most
important physical assessment parameter A. hypertension
the nurse would consider when assessing B. pH below 7.35
fluid and electrolyte imbalance? C. hypoglycemia
D. hyporeflexia
A. skin turgor 48. Vien is receiving oral potassium
B. intake and output supplements for his condition. How
C. osmotic pressure
should the supplements be administered?
D. cardiac rate and rhythm
42. Insensible fluid losses include: A. undiluted
B. diluted
A. urine C. on an empty stomach
B. gastric drainage D. at bedtime
C. bleeding
49. Normal venous blood pH ranges from:
D. perspiration
43. Which of the following intravenous A. 6.8 to 7.2
solutions would be appropriate for a B. 7.31 to 7.41
patient with severe hyponatremia C. 7.35 to 7.45
D. 7.0 to 8.0
secondary to syndrome of inappropriate
50. Respiratory regulation of acids and
antidiuretic hormone (SIADH)?
bases involves:
A. hypotonic solution
B. hypertonic solution A. hydrogen
C. isotonic solution B. hydroxide
D. normotonic solution C. oxygen
D. carbon dioxide
44. Aldosterone secretion in response to
fluid loss will result in which one of the 51. To determine if a patient’s respiratory
following electrolyte imbalances? system is functioning, the nurse would
assess which of the following parameters:
A. hypokalemia
B. hyperkalemia A. respiratory rate
C. hyponatremia B. pulse
D. hypernatremia C. arterial blood gas
D. pulse oximetry
 52. Which of the following conditions is an B. diuretic therapy
equal decrease of extracellular fluid C. diaphoresis
D. all of the following
(ECF) solute and water volume?
59. Nursing interventions for a patient
A. hypotonic FVD with hyponatremia include:
B. isotonic FVD
C. hypertonic FVD A. administering hypotonic IV fluids
D. isotonic FVE B. encouraging water intake
53. When monitoring the daily weight of a C. restricting fluid intake
D. restricting sodium intake
patient with fluid volume deficit (FVD), the
60. The nurse would analyze an arterial
nurse is aware that fluid loss may be
pH of 7.46 as indicating:
considered when weight loss begins to
exceed: A. acidosis
B. alkalosis
A. 0.25 lb C. homeostasis
B. 0.50 lb D. neutrality
C. 1 lb
D. 1 kg Answers and Rationales
1. Answer: A. Assessing dietary
54. Dietary recommendations for a patient intake. Assessing dietary intake provides a
with a hypotonic fluid excess should foundation for the client’s usual practices and
include: may help determine if the client is prone to
constipation or diarrhea. Limited physical
A. decreased sodium intake activity may contribute to constipation due to
B. increased sodium intake decreased peristalsis. Turning, coughing and
C. increased fluid intake deep breathing help promote gas exchange.
D. intake of potassium-rich foods Fluid intake should be increased to aid bowel
55. Osmotic pressure is created through elimination.
the process of: 2. Answer: A. Room temperature
reduction. For patient with hyperthermia,
A. osmosis reducing the room temperature may help
B. diffusion decrease the body temperature. Tepid baths,
C. filtration cool compresses, and cooling blanket may
D. capillary dynamics also be necessary. Antipyretics, and not
56. A rise in arterial pressure causes the antiemetics, are indicated to reduce fever.
baroreceptors and stretch receptors to Oral or rectal temperature measurements are
signal an inhibition of the sympathetic generally accepted and are more accurate than
nervous system, resulting in: axillary measurements. Fluids should be
encouraged, not restricted to compensate for
A. decreased sodium reabsorption insensible losses.
B. increased sodium reabsorption 3. Answer: C. “If I have redness, drainage, or
C. decreased urine output fever, I should call my healthcare
D. increased urine output provider.”. Knowledge that redness,
57. Normal serum sodium concentration drainage, or fever — signs of infection
ranges from: associated with cellular injury — require
reporting indicates that the client has
A. 120 to 125 mEq/L understood the nurse’s discharge teaching.
B. 125 to 130 mEq/L Follow-up checkups should be encouraged
C. 136 to 145 mEq/L with an emphasis of antibiotic compliance
D. 140 to 148 mEq/L even if the client feels better. There are
58. When assessing a patient for usually activity limitations after cellular
electrolyte balance, the nurse is aware injury.
4. Answer: B, D, E. Correct body alignment,
that etiologies for hyponatremia include:
preventing footdrop, and range-of-motion
A. water gain exercises will help prevent contractures.
 Clustering activities will help promote
adequate rest. Monitoring intake and output
and weighing the client will help maintain
fluid and electrolyte balance.
5. Answer: D. Instructing the client to fill a 2-
L bottle with water every night and drink it
the next day. Adequate fluids and fiber in the
diet are key to preventing constipation.
Having the client fill a 2-L bottle with water
every night and drink it the next day is one
method for ensuring the client receives at least
2,000 ml of water daily. The client also should
be instructed to drink any other fluids
throughout the day. High fiber or roughage
foods are encouraged. Laxatives should not be
used routinely for bowel elimination. They
should be used only as a last resort, because
clients may become dependent on them. A
regular bowel evacuation schedule should be
established.
6. Answer: C. The presence of infection may
slow the healing process. Infection impairs
wound healing. Adequate blood supply is
essential for healing. If inadequate, healing is
slowed. Nutritional needs, including protein
and caloric needs, increase for all clients
undergoing cellular repair because adequate
protein and caloric intake is essential to
optimal cellular repair. Elderly clients may
have decreased blood flow to the skin, organ
atrophy and diminished function, and altered
immunity. These conditions slow cellular
repair and increase the risk of infection.
7. Answer: A. Administering anti-
inflammatory agents as prescribed. Anti-
inflammatory agents help reduce edema and
relieve pressure on nerve endings,
subsequently reducing pain. Elevating the
injured area increases venous return to the
heart. Maintaining clean, dry skin aids in
preventing skin breakdown. Cool packs, not
warm packs, should be used initially to cause
vasoconstriction and reduce edema.
8. Answer: B. Having the client perform
Kegel exercises. Kegel exercises, which help
strengthen the muscles in the perineal area,
are used to maintain urinary continence. To
perform these exercises, the client tightens
pelvic floor muscles for 4 seconds 10 times at
least 20 times each day, stopping and starting
the urinary flow. Inserting an indwelling
Foley catheter increases the risk for infection
and should be avoided. The nurse should
encourage the client to develop a toileting
schedule based on normal urinary habits.
However, suggesting bathroom use every 8
hours may be too long an interval to wait.
Pads or diapers should be used only as a
resort.
9. Answer: B. Maintenance of adequate
oxygenation. For the client with asthma and
infection, oxygenation is the priority.
Maintaining adequate oxygenation reduces the
risk of physiologic injury from cellular
hypoxia, which is the leading cause of cell
death. A fluid volume deficit resulting from
fever and diaphoresis, not excess, is more
likely for this client. No information regarding
pain is provided in this scenario. Teaching
about infection control is not appropriate at
this time but would be appropriate before
discharge.
10.Answer: B. Home environment
evaluation. After discharge, the client is
responsible for his own care and health
maintenance management. Discharge includes
assessing the home environment
for determining the client’s ability to maintain
his health at home.
11.Answer: C. Keeping the linens dry and
wrinkle free. Keeping the linens dry and
wrinkle-free aids in preventing moisture and
pressure from interfering with adequate blood
supply to the tissues, helping to maintain skin
integrity. Using a foot board is appropriate for
maintaining normal body function position.
Monitoring intake and output aids in assessing
and maintaining bladder function.. Coughing
and deep breathing help promote gas
exchange.
12.Answer: D. Turn the client to the right side
for 2 hours. Turning the client to the right
side relieves the pressure and promotes
adequate blood supply to the left hip. A
reddened area is never massaged, because this
may increase the damage to the already
reddened, damaged area. The health care
provider does not need to be notified
immediately. However, the health care
provider should be informed of this finding
the next time he is on the unit. Arranging for a
pressure-relieving device is appropriate, but
this is done after the client has been turned.
13.Answer: D. Attempting to rule out
complications before administering pain
medication. When intervening with a client
complaining of pain, the nurse must always
determine if the pain is expected pain or a
complication that requires immediate nursing
intervention. This must be done before
 administering the medication. Guided imagery
should be used along with, not instead of,
administration of pain medication. The nurse
should medicate the client and not discourage
medication.
14.Answer: C. Correct handwashing
technique. Handwashing remains the most
effective procedure for controlling
microorganisms and the incidence of
nosocomial infections. Aseptic technique is
essential with invasive procedures, including
indwelling catheters. Masks, gowns, and
gloves are necessary only when the likelihood
of exposure to blood or body fluids is high.
Spills of blood from clients with acquired
immunodeficiency syndrome should be
cleaned with sodium hydrochloride.
15.Answer: A. Administering I.V. and oral
fluids. The client’s assessment findings would
lead the nurse to suspect that the client is
dehydrated. Administering I.V. fluids is
appropriate. Assessing sputum would be
appropriate for a client with problems
associated with impaired gas exchange or
ineffective airway clearance. Monitoring
albumin and protein levels is appropriate for
clients experiencing inadequate nutrition.
Clustering activities helps with energy
conservation and promotes rest.
16.Answer: D. Orange juice and bananas. The
client with hypokalemia needs to increase the
intake of foods high in potassium. Orange
juice and bananas are high in potassium, along
with raisins, apricots, avocados, beans, and
potatoes. Whole grains and nuts would be
encouraged for the client with
hypomagnesemia; milk products and green,
leafy vegetables are good sources of calcium
for the client with hypocalcemia. Pork
products and canned vegetables are high in
sodium and are encouraged for the client with
hyponatremia.
17.Answer: B. Encouraging slow, deep
breaths. The client who is hyperventilating
and subsequently develops respiratory
alkalosis is losing too much carbon dioxide.
Measures that result in the retention of carbon
dioxide are needed. Encourage slow, deep
breathing to retain carbon dioxide and reverse
respiratory alkalosis. Administering low-flow
oxygen therapy is appropriate for chronic
respiratory acidosis. Administering sodium
bicarbonate is appropriate for treating
metabolic acidosis, and administering sodium
chloride is appropriate for metabolic alkalosis.
18.Answer: C. 2,470. The fluid intake includes 8
oz (240 ml) of apple juice, 850 ml of water, 2
cups (480 ml) of beef broth, and 900 ml of
I.V. fluid for a total of 2,470 ml intake for the
shift.
19.Answer: A. Positive Trousseau’s sign. In a
client with hypocalcemia, a positive
Trousseau’s sign refers to carpopedal spasm
that develops usually within 2 to 5 minutes
after applying and inflating a blood pressure
cuff to about 20 mm Hg higher than systolic
pressure on the upper arm. This spasm occurs
as the blood supply to the ulnar nerve is
obstructed. Chvostek’s sign refers to twitching
of the facial nerve when tapping below the
earlobe. Paresthesia refers to the numbness or
tingling. Tetany is a clinical manifestation of
hypocalcemia denoted by tingling in the tips
of the fingers around the mouth, and muscle
spasms in the extremities and face.
20.Answer: A. Tented skin turgor and
thirst. Hypernatremia refers to elevated serum
sodium levels, usually above 145 mEq/L.
Typically, the client exhibits tented skin
turgor and thirst in conjunction with dry,
sticky mucous membranes, lethargy, and
restlessness. Muscle weakness and paresthesia
are associated with hypokalemia; fruity breath
and Kussmaul’s respirations are associated
with diabetic ketoacidosis. Muscle twitching
and tetany may be seen with hypercalcemia or
hyperphosphatemia.
21.Answer: B. Low PO2. A chronically elevated
PCO2 level (above 50 mmHg) is associated
with inadequate response of the respiratory
center to plasma carbon dioxide. The major
stimulus to breathing then becomes hypoxia
(low PO2). High PCO2 and normal pH and
HCO3 levels would not be the primary stimuli
for breathing in this client.
22.Answer: A. Assessing urinary intake and
output. For the client with fluid volume
deficit, assessing the client’s urine output
(using a urometer if necessary) is essential to
ensure an output of at least 30 ml/hour. The
client should be weighed daily, not weekly,
and at same time each day, usually in the
morning. Monitoring ABGs is not necessary
for this client. Rather, serum electrolyte levels
would most likely be evaluated. The client
also would have an I.V. rate at least 75
ml/hour, if not higher, to correct the fluid
volume deficit.
23.Answer: D. Albert who has renal
disease. Clients with renal disease are
 predisposed to hyperkalemia and should avoid
foods high in potassium. Clients receiving
diuretics, with ileostomies, or with metabolic
acidosis may be hypokalemic and should be
encouraged to eat foods high in potassium.
24.Answer: A. Instituting seizure precaution
to prevent injury. Instituting seizure
precaution is an appropriate intervention,
because the client with hypomagnesemia is at
risk for seizures. Hypophosphatemia may
produce changes in granulocytes, which
would require the nurse to instruct the client
about measures to prevent infection. Avoiding
the use of a tight tourniquet when drawing
blood helps prevent pseudohyperkalemia.
Early ambulation is recommended to reduce
calcium loss from bones during
hospitalization.
25.Answer: D. Sodium. Sodium is the
electrolyte whose level is the primary
determinant of the extracellular fluid
concentration. Sodium a cation (e.g.,
positively charged ion), is the major
electrolyte in extracellular fluid. Chloride, an
anion (e.g., negatively charged ion), is also
present in extracellular fluid, but to a lesser
extent. Potassium (a cation) and phosphate (an
anion) are the major electrolytes in the
intracellular fluid.
26.Answer: B. Kayexalate. The client’s
potassium level is elevated; therefore,
Kayexalate would be ordered to help reduce
the potassium level. Kayexalate is a cation-
exchange resin, which can be given orally, by
nasogastric tube, or by retention enema.
Potassium is drawn from the bowel and
excreted through the feces. Because the
client’s potassium level is already elevated,
potassium supplements would not be given.
Neither calcium gluconate nor sodium tablets
would address the client’s elevated potassium
level.
27.Answer: B. Hot, flushed skin and
diaphoresis. Hypermagnesemia is manifested
by hot, flushed skin and diaphoresis. The
client also may exhibit hypotension, lethargy,
drowsiness, and absent deep tendon reflexes.
Muscle pain and acute rhabdomyolysis are
indicative of hypophosphatemia. Soft-tissue
calcification and hyperreflexia are indicative
of hyperphosphatemia. Increased respiratory
rate and depth are associated with metabolic
acidosis.
28.Answer: C. Potassium level. Diuretics such
as furosemide may deplete serum potassium,
leading to hypokalemia. When the client is
also taking digoxin, the subsequent
hypokalemia may potentiate the action of
digoxin, placing the client at risk for digoxin
toxicity. Diuretic therapy may lead to the loss
of other electrolytes such as sodium, but the
loss of potassium in association with digoxin
therapy is most important. Hypocalcemia is
usually associated with inadequate vitamin D
intake or synthesis, renal failure, or use of
drugs, such as aminoglycosides and
corticosteroids. Hypomagnesemia generally is
associated with poor nutrition, alcoholism,
and excessive GI or renal losses, not diuretic
therapy.
29.Answer: C. Encouraging the client to cough
and deep breathe. The ABG results indicate
respiratory acidosis requiring improved
ventilation and increased oxygen to the lungs.
Coughing and deep breathing can accomplish
this. The nurse would administer high oxygen
levels because the client does not have
chronic obstructive pulmonary disease.
Breathing into a paper bag is appropriate for a
client hyperventilating and experiencing
respiratory alkalosis. Some action is
necessary, because the ABG results are not
within normal limits.
30.Answer: B. Sodium bicarbonate. Metabolic
acidosis results from excessive absorption or
retention of acid or excessive excretion of
bicarbonate. A base is needed. Sodium
bicarbonate is a base and is used to treat
documented metabolic acidosis. Potassium,
serum sodium determinations, and a
bronchodilator would be inappropriate orders
for this client.
31.Answer: C. within normal range. Normal
serum concentrations of chloride range from
95 to 108 mEq/L.
32.Answer: C. eclampsia. Eclampsia is
associated with increased levels of serum
chloride.
33.Answer: C. anion. Chloride is a major anion
found in the extracellular fluid. A compound
occurs when two ions are bound together.
Chloride is an ion, but this choice is too
general. HCO3 is a cation.
34.Answer: A. amphogel. Administration of
phosphate binders (amphogel and basagel)
will reduce the serum phosphate levels.
35.Answer: C. metastatic bone
lesions. Metastatic bone lesions are associated
with hypercalcemia due to accelerated bone
metabolism and release of calcium into the
 serum. Renal failure, inadequate calcium
intake, and vitamin D deficiency may cause
hypocalcemia.
36.Answer: D. urinary calculi. Urinary calculi
may occur with hypercalcemia. Shortened, not
prolonged QRS complex would be seen in
hypercalcemia. Tetany and petechiae are signs
of hypocalcemia.
37.Answer: B. administering calcium
gluconate. Calcium gluconate is used for
replacement in deficiency states. Calcitonin
and loop diuretics are used to lower serum
calcium.
38.Answer: D. renal failure. Renal failure can
reduce magnesium excretion, leading to
hypermagnesemia. Diabetic ketoacidosis, not
insulin shock is a cause of hypermagnesemia.
Hypoadrenalism, not hyperadrenalism is a
cause of hypermagnesemia. Nausea and
vomiting lead to hypomagnesemia.
39.Answer: B. antagonize the cardiac effects
of magnesium. In a patient with
hypermagnesemia, administration of calcium
gluconate will antagonize the cardiac effects
of magnesium. Although calcium gluconate
will raise serum calcium levels, that is not the
purpose of administration. Calcium gluconate
does not lower calcium or magnesium levels.
40.Answer: B. Digoxin. In hypomagnesemia, a
patient on digoxin is likely to develop digitalis
toxicity. Neither A nor C has toxicity as a side
effect. CAPD is not a medication.
41.Answer: D. cardiac rate and
rhythm. Cardiac rate and rhythm are the most
important physical assessment parameter to
measure. Skin turgor, intake and output are
physical assessment parameters a nurse would
consider when assessing fluid and electrolyte
imbalance, but choice d is the most important.
42.Answer: D. perspiration. Perspiration and
the fluid lost via the lungs are termed
insensible losses; normally, insensible losses
equal about 1000 cc/day.
43.Answer: B. hypertonic solution. When
hyponatremia is severe, hypertonic solutions
may be used but should be infused with
caution due to the potential for development
of CHF. In SIADH, isotonic and hypotonic
solutions are not indicated, because urine
output is minimal, so water is retained. this
water retention dilutes serum sodium levels,
making the patient hyponatremic and
necessitating administration of hypertonic
solutions to balance sodium and water.
Normotonic solutions do not exist.
44.Answer: A. hypokalemia. Aldosterone is
secreted in response to fluid loss. Aldosterone
causes sodium reabsorption and potassium
elimination, further exacerbating
hypokalemia.
45.Answer: A. bounding pulse. Bounding pulse
is a sign of fluid overload as more volume in
the vessels causes a stronger sensation against
the blood vessel walls. Flat neck veins and
vesicular breath sounds are normal findings.
Poor skin turgor is consistent with
dehydration.
46.Answer: B. diluted in 100 cc over 1
hour. Potassium must be well diluted and
given slowly because rapid administration
will cause cardiac arrest.
47.Answer: D. hyporeflexia. Hyporeflexia is a
symptom of hypokalemia
48.Answer: B. diluted. Oral potassium
supplements are known to irritate
gastrointestinal (GI) mucosa and should be
diluted.
49.Answer: B. 7.31 to 7.41. Normal venous
blood pH ranges from 7.31 to 7.41. Normal
arterial blood pH ranges from 7.35 to 7.45.
50.Answer: D. carbon dioxide. Respiratory
regulation of acid-base balance involves the
elimination or retention of carbon dioxide.
51.Answer: C. arterial blood gas. Arterial
blood gases will indicate CO2 and O2 levels.
This is an indication that the respiratory
system is functioning. Respiratory rate can
reveal data about other systems, such as the
brain, making letter c a better choice. Pulse
rate is not measure of respiratory status. Pulse
oximetry yields oxygen saturation levels,
which is not a measure of acid-base balance.
52.Answer: B. isotonic FVD. Isotonic FVD
involves an equal decrease in solute
concentration and water volume.
53.Answer: B. 0.50 lb. Weight loss of more than
0.50 lb. is considered to be fluid loss.
54.Answer: B. increased sodium
intake. Hypotonic fluid volume excess (FVE)
involves an increase in water volume without
an increase in sodium concentration.
Increased sodium intake is part of the
management of this condition.
55.Answer: B. diffusion. In diffusion, the solute
moves from an area of higher concentration to
one of lower concentration, creating osmotic
pressure. Osmotic pressure is related to the
process of osmosis. Filtration is created by
hydrostatic pressure. Capillary dynamics are
 related to fluid exchange at the intravascular
and interstitial levels.
56.Answer: D. increased urine output. Arterial
baroreceptors and stretch receptors help
maintain fluid balance by increasing urine
output in response to a rise in arterial
pressure.
57.Answer: C. 136 to 145 mEq/L. Normal
serum sodium level ranges from 136 to 145
mEq/L.
58.Answer: D. all of the following. Water gain,
diuretic therapy, and diaphoresis are etiologies
of hyponatremia.
59.Answer: C. restricting fluid
intake. Hyponatremia involves a decreased
concentration of sodium in relation to fluid
volume, so restricting fluid intake is indicated.
60.Answer: B. alkalosis. Alkalosis is indicated
by a pH above 7.45.
 NCLEX Practice Exam for F&E & Homeostasis 2 B. pH 7.48, PaCO2 46, HCO3 30
C. pH 7.48, PaCO2 34, HCO3 20
1.The net diffusion of water from one D. pH 7.48, PaCO2 34, HCO3 26
solution of water from one solution 7. The body’s compensation of metabolic
through a semipermeable membrane to alkalosis involves:
another solution containing a lower
concentration of water is termed: A. increasing the respiratory rate
B. decreasing the respiratory rate
A. filtration C. increasing urine output
B. diffusion D. decreasing urine output
C. osmosis 8. When assessing a patient for metabolic
D. brownian motion alkalosis, the nurse would expect to find:
2. When assessing a patient’s total body
water percentage, the nurse is aware that A. low serum potassium
all of the following factors influence this B. changes in urine output
C. hypotension
except:
D. increased CVP
A. age 9. Which of the following blood products
B. fat tissue should be infused rapidly?
C. muscle mass
D. gender A. packed red blood cells (PRBC)
3. Orly Khan is suffering from fluid volume B. fresh frozen plasma (FFP)
C. platelets
deficit (FVD), which of the following
D. dextran
symptoms would the nurse expect to
10. Which of the following statements
assess in the patient?
provides the rationale for using a
A. rales hypotonic solution for a patient with FVD?
B. bounding pulse
C. tachycardia A. A hypotonic solution provides free water to
D. bulging neck veins help the kidneys eliminate the solute.
B. A hypotonic solution supplies an excess of
4. John Reid is admitted in the hospital
sodium and chloride ions.
and is currently receiving hypertonic C. Excessive volumes are recommended in the
fluids. Nursing management for the client early postoperative period.
includes monitoring for all of the following D. A hypotonic solution is used to treat
potential complications except: hyponatremia.
11. Brad is receiving a blood transfusion.
A. water intoxication
When monitoring the patient, the nurse
B. fluid volume excess (FVE)
C. cellular dehydration would analyze an elevated body
D. cell shrinkage temperature as indicating:
5. Mr. Alberto is scheduled to receive an A. a normal physiologic process
isotonic solution; which one of the B. evidence of sepsis
following is an example of such solution? C. a possible transfusion reaction
D. an expected response to the transfusion
A. D10% W
12. The process of endocrine regulation
B. 0.45% saline
C. 0.9% saline of electrolytes involves:
D. 3% normal saline W A. sodium reabsorption and chloride excretion
6. Which of the following arterial blood B. chloride reabsorption and sodium excretion
gas (ABG) values indicates C. potassium reabsorption and sodium excretion
uncompensated metabolic alkalosis? D. sodium reabsorption and potassium excretion
13. The chief anion in the intracellular
A. pH 7.48, PaCO2 42, HCO3 30
fluid (ICF) is:
A. phosphorus D. calcitonin
B. potassium 21. The presence of which of the
C. sodium following electrolytes contributes to
D. chloride
acidosis?
14. The major cation in the ICF is:
A. sodium
A. potassium B. potassium
B. sodium C. hydrogen
C. phosphorus D. chloride
D. magnesium
22. The lungs participate in acid-base
15. Hypophosphatemia may result from
balance by:
which of the following diseases?
A. reabsorbing bicarbonate
A. liver cirrhosis B. splitting carbonic acid in two
B. renal failure C. using CO2 to regulate hydrogen ions
C. Paget’s disease D. sending hydrogen ions to the renal tubules
D. alcoholism
23. The respiratory system regulates
16. A patient with which of the following
acid-base balance by:
disorders is at high risk for developing
hyperphosphatemia? A. increasing mucus production
B. changing the rate and depth of respirations
A. hyperkalemia C. forming bicarbonate
B. hyponatremia D. reabsorbing bicarbonate
C. hypocalcemia 24. Which of the following is a gas
D. hyperglycemia
component of the ABG measurement?
17. Normal calcium levels must be
analyzed in relation to: A. carbon dioxide
B. bicarbonate
A. sodium C. hydrogen
B. glucose D. pH
C. protein 25. Chloride helps maintain acid-base
D. fats
balance by performing which of the
18. Calcium is absorbed in the GI tract
following roles?
under the influence of:
A. participating in the chloride shift
A. vitamin D B. following sodium to maintain serum
B. glucose osmolarity
C. HCl C. maintaining the balance of cations in the ICF
D. vitamin C and ECF
19. Which of the following diagnoses is D. separating carbonic acid
most appropriate for a patient with hypo 26. Which of the following hormones
calcemia? helps regulate chloride reabsorption?
A. constipation, bowel A. antidiuretic hormone
B. high risk for injury: bleeding B. renin
C. airway clearance, ineffective C. estrogen
D. high risk for injury: confusion D. aldosterone
20. When serum calcium levels rise, 27. Chloride is absorbed in the:
which of the following hormones is
A. stomach
secreted?
B. bowel
A. aldosterone C. liver
B. renin D. kidney
C. parathyroid hormone
 28. When chloride concentration drops C. urine analysis, particularly for the presence of
below 95 mEq/L, reabsorption of which of white blood cells
D. EEG results
the following electrolytes increases
33. When teaching a patient about foods
proportionally?
high in magnesium, the nurse would
A. hydrogen include:
B. potassium
C. sodium A. green vegetables
D. bicarbonate B. butter
29. Jonas is admitted with 1,000 ml of C. cheese
D. tomatoes
diarrhea per day for the last 3 days. An IV
34. The balance of anions and cations as
of 0.45% NaCl mixed with 5% dextrose is
it occurs across cell membranes is known
infusing. Which of the following nursing
as:
interventions is the most appropriate?
A. osmotic activity
A. Get an infusion controller from central supply.
B. electrical neutrality
B. Mix all antibiotics in 0.45% NaCl with 5%
C. electrical stability
dextrose.
D. sodium-potassium pump
C. Check the patient’s potassium level and
contact the doctor for IV additive orders. 35. Maria, an 85-year-old patient with a
D. Assess the patient for signs of hyperkalemia. feeding tube, has been experiencing
30. Mrs. Waltraud is receiving digoxin and severe watery stool. The patient is
Lasix daily. Today, she complains of lethargic and has poor skin turgor, a pulse
nausea, and her apical pulse is 130 and of 120, and hyperactive reflexes. Nursing
irregular. Which of the following nursing interventions would include:
interventions is the most appropriate? A. measuring and recording intake and output
A. Hold the digoxin and check the patient’s and daily weights
potassium level. B. administering salt tablets and monitoring
B. Remove the orange juice from the patient’s hypertonic parenteral solutions
tray. C. administering sedatives
C. Identify the patient as high risk for D. applying wrist restraints to avoid
hyperkalemia. displacement of the feeding tube
D. Assess the patient for other signs of 36. Disease of which of the following
hypernatremia. structures is most likely to affect
31. The type of fluid used to manipulate electrolyte reabsorption?
fluid shifts among compartments states is:
A. glomerulus
A. whole blood B. renal tubules
B. TPN C. bladder
C. albumin D. renal pelvis
D. Ensure 37. Analiza is diagnosed with
32. Mr. Miyazaki who is diagnosed of hypermagnesemia. Symptoms of her
bipolar disorder has been drinking condition may include:
copious amounts of water and voiding
A. hypertension
frequently. The patient is experiencing B. tachycardia
muscle cramps, twitching, and is reporting C. hyperactive deep-tendon reflex
dizziness. the nurse checks lab work for: D. cardiac arrhythmias
38. Daniel who is a marathon runner is at
A. complete blood count results, particularly the
platelets. high risk for fluid volume deficit. Which
B. electrolytes, particularly the serum sodium one of the following is a related factor?
A. decreased diuresis A. poor skin turgor and increased thirst
B. disease-related process B. weight gain and thirst
C. decreased breathing and perspiration C. interstitial edema and hypertension
D. increased breathing and perspiration D. hypotension and pitting edema
39. Jordan is diagnosed with FVD; which 46. The interstitial space holds
of the following nursing diagnoses might approximately how many liters?
apply to his condition?
A. 3L
A. altered urinary elimination B. 6L
B. decreased cardiac output C. 9L
C. increased cardiac output D. 12 L
D. vomiting 47. Sodium balance is important for which
40. Body fluids perform which of the of the following functions?
following functions?
A. transmitting impulses in nerve and muscle
A. transport nutrients fibers via the calcium-potassium pump
B. transport electrical charges B. exchanging for magnesium and attracting
C. cushion the organs chloride
D. facilitate fat metabolism C. combining with hydrogen and chloride for
41. Sodium levels are affected by the acid-base balance
D. exchanging for potassium and attracting
secretion of which of the following
chloride
hormones?
48. In renal regulation of water balance,
A. progesterone and aldosterone the functions of angiotensin II include:
B. ADH and ACTH
C. antidiuretic hormone and FSH A. blood clotting within the nephron
D. ECF and aldosterone B. increasing progesterone secretion into the
renal tubules
42. Bicarbonate is lost during which of the
C. catalyzing calcium-rich nutrients
following clinical conditions? D. selectively constricting portions of the
A. diarrhea arteriole in the nephron
B. diuresis 49. Which of the following nursing
C. diaphoresis diagnoses might apply to a patient with
D. vomiting hypertonic FVE?
43. Magnesium reabsorption is controlled
A. ineffective airway clearance
by:
B. potential for decreased cardiac output
A. Loop of Henle C. ineffective breathing pattern
B. glomerulus D. potential for increased cardiac output
C. pituitary 50. The intracellular compartment holds
D. parathyroid hormone water and:
44. Heidi has a nursing diagnosis of fluid
A. proteins
volume deficit. Which one of the following
B. glucose
medications could potentially exacerbate C. sodium
the problem? D. uric acid
A. Synthroid 51. The majority gastrointestinal
B. Digoxin reabsorption of water occurs in:
C. Lasix
A. small intestines
D. insulin
B. the esophagus
45. Alexander has hypotonic FVE; which C. the colon
of the following findings would the nurse D. the stomach
expect to assess in the patient? 52. Isotonic FVD can result from:
A. GI fluid loss through diarrhea C. a diet including 4 gm sodium
B. insensible water loss during prolonged fever D. a 1500 calorie weight-loss diet
C.  inadequate ingestion of fluids and electrolytes 60. Which of the following electrolytes are
D. impaired thirst regulation lost as a result of vomiting?
53. The majority of the body’s water is
contained in which of the following fluid A. bicarbonate and calcium
B. sodium and hydrogen
compartments?
C. sodium and potassium
A. intracellular D. hydrogen and potassium
B. interstitial Answers and Rationales
C. intravascular 1. Answer: C. osmosis. Osmosis is defined as
D. extracellular the diffusion of water through a
54. Etiologies associated with semipermeable membrane to a solution with a
hypomagnesemia include: lower concentration of water. Filtration is the
process in which fluids are pushed through
A. decreased vitamin D intake biologic membranes by unequal processes.
B. constipation Diffusion (Brownian motion) is the random
C. malabsorption syndrome kinetic motion causing atoms and molecules
D. renal failure to spread out evenly.
55. The danger of fluid sequestered in the 2. Answer: D. gender. A patient’s gender does
third space is that the fluid: not influence the percentage of total body
water.
A. is hypertonic and can cause hypervolemia 3. Answer: C. tachycardia. Tachycardia, poor
B. is hypotonic and can cause water intoxication tissue turgor, and hypotension are symptoms
C. is not available for circulation of FVD. Other choices are symptoms of FVE.
D. contains large amounts of acids 4. Answer: A. water intoxication. Water
56. The extracellular fluid space holds intoxication is a potential complication
water, electrolytes, proteins and: associated with hypotonic fluid
administration. Other choice are potential
A. red blood cells complication of hypertonic fluid
B. potassium administration.
C. lipids 5. Answer: C. A solution of 0.9% saline is
D. nucleic acids isotonic. A solution of 0.9% saline is isotonic.
57. Magnesium performs all of the Solutions of 0.33% and 0.45% saline and
following functions except: D5W are hypotonic.
6. Answer: A. pH 7.48, PaCO2 42, HCO3
A. contributing to vasoconstriction 30. Uncompensated metabolic alkalosis is
B.  assisting in cardiac muscle contraction indicated by ABG values of pH 7.48, PaCO2
C. facilitating sodium transport 42, and HCO3 30. B indicates metabolic
D. assisting in protein metabolism alkalosis, partially compensated. C indicates
58. Which of the following clinical respiratory alkalosis, partially compensated. D
conditions exacerbates electrolyte indicates respiratory alkalosis,
uncompensated.
excretion? 7. Answer: B. decreasing the respiratory
A. nasogastric feedings rate. The body attempts to compensate for
B. use of surgical drains metabolic alkalosis by decreasing the
C. immobility from fractures respiratory rate and conserving carbon dioxide
D. chronic water drinking (an acid). Urine volume does not influence
acid-base balance.
59. A diet containing the minimum daily
8. Answer: A. low serum
sodium requirement for an adult would potassium. Decreased serum potassium is a
be: common symptom of metabolic alkalosis.
9. Answer: C. platelets. Platelets and
A. a no-salt diet
cryoprecipitate can be infused quickly. PRBC
B. a diet including 2 gm sodium
 and FFP should be administered over 1 ½ to 4
hours. Dextran is not a blood product.
10.Answer: A. A hypotonic solution provides
free water to help the kidneys eliminate the
solute. Hypotonic solutions provide free
water, which helps the kidneys eliminate
solute.
11.Answer: C. a possible transfusion
reaction. An increase in the body temperature
indicates a possible transfusion reaction and
requires immediate discontinuation of the
infusion.
12.Answer: D. sodium reabsorption and
potassium excretion. ACTH stimulates
release of aldosterone, which in turn acts on
the tubules to reabsorb sodium. When this
occurs, the cation potassium is excreted.
13.Answer: A. phosphorus. Phosphorus is the
major ICF cation. Potassium and sodium are
cations. Chloride is the chief anion found in
the ECF.
14.Answer: A. potassium. Potassium is the
major ICF cation. Sodium is the major ECF
cation. Phosphorus is the major ICF anion.
Magnesium is the second-most abundant
cation in the ICF.
15.Answer: D. alcoholism. Hypophosphatemia
may occur secondary to alcoholism. Renal
failure is usually associated with
hyperphosphatemia
16.Answer: C. hypocalcemia. Because calcium
and phosphorus ratios are inversely
proportional, when phosphorus levels are
high, calcium levels are low.
17.Answer: C. protein. Some calcium is bound
to protein, so abnormal calcium levels are
analyzed in relation to proteins.
18.Answer: A. vitamin D. Calcium is absorbed
in the GI tract under the influence of vitamin
D in its biologically active form.
19.Answer: B. high risk for injury:
bleeding. A patient with hypocalcemia may
bleed, since calcium is required for normal
blood clotting. A and D are diagnoses
appropriate for a patient with hypercalcemia.
C is not associated with fluctuating calcium
levels.
20.Answer: D. calcitonin. When calcium levels
rise, calcitonin is secreted from the thyroid;
this hormone moves calcium from plasma into
bone. Parathyroid hormone is secreted in
response to lowered calcium levels; this
hormone moves calcium from bone into
plasma.
21.Answer: C. hydrogen. The presence of
hydrogen ions determines a solution’s acidity.
22.Answer: C. using CO2 to regulate
hydrogen ions. The lungs use carbon dioxide
to regulate hydrogen ion concentration.
23.Answer: B. changing the rate and depth of
respirations. Through changes in the rate and
depth of respirations, acid-base balance is
achieved via CO2 elimination and retention.
Mucus production is not part of the
pulmonary regulatory system. C and D are
responses that refer to ways in which kidneys
balance acids and bases.
24.Answer: A. carbon dioxide. The gases
measured by ABGs are oxygen and carbon
dioxide. Bicarbonate and hydrogen are ions;
their ratio is measured in the pH.
25.Answer: A. participating in the chloride
shift. To maintain acid-base balance, chloride
shifts into and out of red blood cells in
exchange for bicarbonate.
26.Answer: D. aldosterone. Chloride
reabsorption depends on sodium reabsorption,
which is regulated by aldosterone in the distal
tubule and collecting ducts.
27.Answer: B. bowel. Chloride is absorbed in
the bowel, mainly the duodenum and jejunum.
28.Answer: D. bicarbonate. When chloride
concentrations drop below 95 mEq/L,
bicarbonate reabsorption increases
proportionally, causing metabolic alkalosis.
Other choices are cations, chloride is an
anion; a cation must always exchange for a
cation in order to maintain electrical
neutrality.
29.Answer: C. Check the patient’s potassium
level and contact the doctor for IV additive
orders. Potassium is lost via the GI and renal
systems. Prolonged or excessive diarrhea can
lead to hypokalemia. In the event of
hypokalemia, a potassium additive would
likely be prescribed.
30.Answer: A. Hold the digoxin and check the
patient’s potassium level. Patient
experiencing hypokalemia are at risk for
digitalis toxicity. Nausea and irregular pulse
are signs digitalis toxicity.
31.Answer: C. albumin. Albumin is a colloid
that is used to manipulate fluid shifts among
compartments. Whole blood is used to replace
blood volume. TPN is used for patients who
are unable to take in food or fluid. Ensure is
high caloric nutritional supplement; it is not
used to manipulate fluid shifts.
32.Answer: B. electrolytes, particularly the
serum sodium. The patient is exhibiting
behavior that could lead to a sodium and
water imbalance and is exhibiting signs of
hyponatremia. The nurse would check the
electrolytes with attention to the sodium level.
33.Answer: A. green vegetables. Green
vegetables are high in magnesium.
34.Answer: B. electrical neutrality. Electrical
neutrality refers to a state in which the same
number of positively charged ions and
negatively charged ions are present on either
side of the membrane. Osmotic activity refers
to the attraction of a solute to a solvent.
Sodium-potassium pump refers to the
exchange of electrolytes.
35.Answer: A. measuring and recording
intake and output and daily weights. The
patient is exhibiting signs of hypernatremia
and dehydration. The most appropriate
nursing intervention is to measure and record
intake and output and daily weight.
36.Answer: B. renal tubules. The renal tubules
are the site of electrolyte reabsorption. The
glomerulus is the site of electrolyte filtration.
The bladder is where the urine is stored. The
renal pelvis is where urine travels as it moves
from the collecting ducts to the ureter.
37.Answer: D. cardiac arrhythmias. Cardiac
arrhythmias are associated with
hypermagnesemia. Hypertension, tachycardia,
and hyperactive reflexes are signs of
hypomagnesemia.
38.Answer: D. increased breathing and
perspiration. Excessive fluid can be lost if
breathing and perspiration are at an increased
rate for a prolonged period.
39.Answer: B. decreased cardiac
output. Decreased cardiac output is a nursing
diagnosis associated with isotonic FVD. Other
appropriate nursing diagnoses include altered
tissue perfusion, potential for injury, and
ineffective breathing pattern.
40.Answer: A. transport nutrients. Body fluids
facilitate the transport of nutrients, hormones,
proteins, and other molecules.
41.Answer: B. ADH and ACTH. The endocrine
system secretes aldosterone and ADH to help
regulate sodium levels. The pituitary secretes
adrenocorticotropin hormone to help regulate
sodium. A and C are reproductive hormones.
ECF is not a hormone.
42.Answer: A. diarrhea. Bicarbonate is lost in
diarrhea because the lower intestinal tract
contains fluids rich in bicarbonate.
43.Answer: A. Loop of Henle. The Loop of
Henle is responsible for magnesium
reabsorption.
44.Answer: C. Lasix. Lasix will contribute to
fluid loss through its action as a diuretic.
45.Answer: B. weight gain and thirst. Weight
gain and thirst are symptoms of hypotonic
FVE; other symptoms include excretion of
dilute urine, non-pitting edema, dysrhythmias,
and hyponatremia.
46.Answer: C. 9 L. The interstitial space hold 9
L.
47.Answer: D. exchanging for potassium and
attracting chloride. Sodium influences the
levels of potassium and chloride by
exchanging for potassium and attracting
chloride.
48.Answer: D. selectively constricting portions
of the arteriole in the nephron. As part of
the renal regulation of water balance,
angiotensin II selectively constricts portions
of the arteriole in the nephron.
49.Answer: B. potential for decreased cardiac
output. Potential for decreased cardiac output
is a nursing diagnosis associated with
hypertonic FVE.
50.Answer: A. proteins. The intracellular
compartment holds large amounts of water
and proteins. Potassium, lipids, and nucleic
acids are also components of the intracellular
compartment.
51.Answer: A. small intestines. Approximately
85% to 95% of water absorption takes place in
the small intestine. The colon absorbs only
500 to 100 cc.
52.Answer: C. inadequate ingestion of fluids
and electrolytes. Isotonic FVD may result
from inadequate intake of fluids and
electrolytes that can occur secondary to an
inability to ingest orally. GI fluid loss through
diarrhea is an etiology of hypotonic FVD.
Insensible water loss during prolonged fever
is a cause of hypertonic FVD. Impaired thirst
regulation is a cause of hypertonic FVD.
53.Answer: A. intracellular. The intracellular
compartment holds two-thirds of total body
water. The extracellular compartment is the
interstitial space plus the intravascular space.
The extracellular compartment accounts for
one-third of total body water.
54.Answer: C. malabsorption
syndrome. Malabsorption syndrome is
associated with hypomagnesemia. Increased
vitamin D intake and diarrhea are also
associated with hypomagnesemia.
55.Answer: C. is not available for
circulation. In third-spacing, fluid is
sequestered and is unavailable to the general
circulation.
56.Answer: A. red blood cells. The extracellular
space contains red blood cells, white blood
cells, and platelets in addition to water,
electrolytes, and proteins. Potassium, lipids,
and nucleic acids are intracellular
components.
57.Answer: A. contributing to
vasoconstriction. Magnesium contributes to
vasodilation, not vasoconstriction.
58.Answer: B. use of surgical drains. Surgical
drains will cause a fluid loss, and electrolytes
are eliminated along with the fluid.
59.Answer: B. a diet including 2 gm
sodium. The minimum sodium requirement
for adults is 2 gm daily. Most adults consume
more than this because sodium is abundant in
almost all foods.
60.Answer: D. hydrogen and potassium. In
upper gastrointestinal fluid loss, hydrogen and
potassium are lost because these electrolytes
are present in abundance in the stomach.
 NCLEX Practice Exam for Renal Disorders 1 B. 30 minutes
C. 1 hour
1. Which of the following symptoms do D. 2 to 3 hours
you expect to see in a patient diagnosed 7. A 30 y.o. female patient is undergoing
with acute pyelonephritis? hemodialysis with an internal
A. Jaundice and flank pain arteriovenous fistula in place. What do
B. Costovertebral angle tenderness and chills you do to prevent complications
C. Burning sensation on urination associated with this device?
D. Polyuria and nocturia
2. You have a patient that might have a A. Insert I.V. lines above the fistula.
B. Avoid taking blood pressures in the arm with
urinary tract infection (UTI). Which
the fistula.
statement by the patient suggests that a C. Palpate pulses above the fistula.
UTI is likely? D. Report a bruit or thrill over the fistula to the
doctor.
A. “I pee a lot.”
B. “It burns when I pee.” 8. Your patient becomes restless and tells
C. “I go hours without the urge to pee.” you she has a headache and feels
D. “My pee smells sweet.” nauseous during hemodialysis. Which
3. Which instructions do you include in complication do you suspect?
the teaching care plan for a patient with
A. Infection
cystitis receiving phenazopyridine B. Disequilibrium syndrome
(Pyridium). C. Air embolus
D. Acute hemolysis
A. If the urine turns orange-red, call the doctor.
B. Take phenazopyridine just before urination to 9.   Your patient is complaining of muscle
relieve pain. cramps while undergoing hemodialysis.
C. Once painful urination is relieved, discontinue Which intervention is effective in relieving
prescribed antibiotics. muscle cramps?
D. After painful urination is relieved, stop taking
phenazopyridine. A. Increase the rate of dialysis
4. Which patient is at greatest risk for B. Infuse normal saline solution
C. Administer a 5% dextrose solution
developing a urinary tract infection (UTI)?
D. Encourage active ROM exercises
1. A 35 y.o. woman with a fractured wrist 10.  Your patient with chronic renal failure
2. A 20 y.o. woman with asthma reports pruritus. Which instruction should
3. A 50 y.o. postmenopausal woman you include in this patient’s teaching
4. A 28 y.o. with angina
plan?
5. You have a patient that is receiving
peritoneal dialysis. What should you do A. Rub the skin vigorously with a towel
when you notice the return fluid is slowly B. Take frequent baths
C. Apply alcohol-based emollients to the skin
draining?
D. Keep fingernails short and clean
A. Check for kinks in the outflow tubing. 11.  Which intervention do you plan to
B. Raise the drainage bag above the level of the include with a patient who has renal
abdomen. calculi?
C. Place the patient in a reverse Trendelenburg
position. A. Maintain bed rest
D. Ask the patient to cough. B. Increase dietary purines
6. What is the appropriate infusion time C. Restrict fluids
for the dialysate in your 38 y.o. patient D. Strain all urine
with chronic renal failure? 12.  An 18 y.o. student is admitted with
dark urine, fever, and flank pain and is
A. 15 minutes diagnosed with acute glomerulonephritis.
 Which would most likely be in this 19.  Immediately post-op after a
student’s health history? prostatectomy, which complications
requires priority assessment of your
A. Renal calculi
B. Renal trauma patient?
C. Recent sore throat A. Pneumonia
D. Family history of acute glomerulonephritis B. Hemorrhage
13.  Which drug is indicated for pain C. Urine retention
related to acute renal calculi? D. Deep vein thrombosis
20.  The most indicative test for prostate
A. Narcotic analgesics
B. Nonsteroidal anti-inflammatory drugs cancer is:
(NSAIDS) A. A thorough digital rectal examination
C. Muscle relaxants B. Magnetic resonance imaging (MRI)
D. Salicylates C. Excretory urography
14.  Which of the following causes the D. Prostate-specific antigen
majority of UTI’s in hospitalized patients? 21.  A 22 y.o. patient with diabetic
A. Lack of fluid intake nephropathy says, “I have two kidneys
B. Inadequate perineal care and I’m still young. If I stick to my insulin
C. Invasive procedures schedule, I don’t have to worry about
D. Immunosuppression kidney damage, right?” Which of the
15.  Clinical manifestations of acute following statements is the best
glomerulonephritis include which of the response?
following?
A. “You have little to worry about as long as
A. Chills and flank pain your kidneys keep making urine.”
B. Oliguria and generalized edema B. “You should talk to your doctor because
C. Hematuria and proteinuria statistics show that you’re being unrealistic.”
D. Dysuria and hypotension C. “You would be correct if your diabetes could
16.  You expect a patient in the oliguric be managed with insulin.”
phase of renal failure to have a 24 hour D. “Even with insulin, kidney damage is still a
concern.”
urine output less than:
22.  A patient diagnosed with sepsis from
A. 200ml a UTI is being discharged. What do you
B. 400ml plan to include in her discharge teaching?
C. 800ml
D. 1000ml A. Take cool baths
17.  The most common early sign of B. Avoid tampon use
kidney disease is: C. Avoid sexual activity
D. Drink 8 to 10 eight-oz glasses of water daily
A. Sodium retention 23.  You’re planning your medication
B. Elevated BUN level teaching for your patient with a UTI
C. Development of metabolic acidosis prescribed phenazopyridine (Pyridium).
D. Inability to dilute or concentrate urine
What do you include?
18.  A patient is experiencing which type
of incontinence if she experiences leaking A. “Your urine might turn bright orange.”
urine when she coughs, sneezes, or lifts B. “You need to take this antibiotic for 7 days.”
heavy objects? C. “Take this drug between meals and at
bedtime.”
A. Overflow D. “Don’t take this drug if you’re allergic to
B. Reflex penicillin.”
C. Stress
D. Urge
 24.  Which finding leads you to suspect
acute glomerulonephritis in your 32 y.o.
patient?
A. Dysuria, frequency, and urgency
B. Back pain, nausea, and vomiting
C. Hypertension, oliguria, and fatigue
D. Fever, chills, and right upper quadrant pain
radiating to the back
25.  What is the priority nursing diagnosis
with your patient diagnosed with end-
stage renal disease?
A. Activity intolerance
B. Fluid volume excess
C. Knowledge deficit
D. Pain
26.  A patient with ESRD has an
arteriovenous fistula in the left arm for
hemodialysis. Which intervention do you
include in his plan of care?
A. Apply pressure to the needle site upon
discontinuing hemodialysis
B. Keep the ehad of the bed elevated 45 degrees
C. Place the left arm on an arm board for at least
30 minutes
D. Keep the left arm dry
27.  Your 60 y.o. patient with
pyelonephritis and possible septicemia
has had five UTIs over the past two
years. She is fatigued from lack of sleep,
has lost weight, and urinates frequently
even in the night. Her labs show: sodium,
154 mEq/L; osmolarity 340 mOsm/L;
glucose, 127 mg/dl; and potassium, 3.9
mEq/L. Which nursing diagnosis is
priority?
A. Fluid volume deficit related to osmotic
diuresis induced by hyponatremia
B. Fluid volume deficit related to inability to
conserve water
C. Altered nutrition: Less than body
requirements related to hypermetabolic state
D. Altered nutrition: Less than body
requirements related to catabolic effects of
insulin deficiency
28.  Which sign indicated the second
phase of acute renal failure?
A. Daily doubling of urine output (4 to 5 L/day)
B. Urine output less than 400 ml/day
C. Urine output less than 100 ml/day
D. Stabilization of renal function
29.  Your patient had surgery to form an
arteriovenous fistula for hemodialysis.
Which information is important for
providing care for the patient?
A. The patient shouldn’t feel pain during
initiation of dialysis
B. The patient feels best immediately after the
dialysis treatment
C. Using a stethoscope for auscultating the
fistula is contraindicated
D. Taking a blood pressure reading on the
affected arm can cause clotting of the fistula
30.  A patient with diabetes mellitus and
renal failure begins hemodialysis. Which
diet is best on days between dialysis
treatments?
A. Low-protein diet with unlimited amounts of
water
B. Low-protein diet with a prescribed amount of
water
C. No protein in the diet and use of a salt
substitute
D. No restrictions
31.  After the first hemodialysis treatment,
your patient develops a headache,
hypertension, restlessness, mental
confusion, nausea, and vomiting. Which
condition is indicated?
A. Disequilibrium syndrome
B. Respiratory distress
C. Hypervolemia
D. Peritonitis
32.  Which action is most important during
bladder training in a patient with a
neurogenic bladder?
A. Encourage the use of an indwelling urinary
catheter
B. Set up specific times to empty the bladder
C. Encourage Kegel exercises
D. Force fluids
33.  A patient with diabetes has had many
renal calculi over the past 20 years and
now has chronic renal failure. Which
substance must be reduced in this
patient’s diet?
A. Carbohydrates
B. Fats 39.  You’re developing a care plan with
C. Protein the nursing diagnosis risk for infection for
D. Vitamin C
your patient that received a kidney
34.  What is the best way to check for
transplant. A goal for this patient is to:
patency of the arteriovenous fistula for
hemodialysis? A. Remain afebrile and have negative cultures
B. Resume normal fluid intake within 2 to 3 days
A. Pinch the fistula and note the speed of filling C. Resume the patient’s normal job within 2 to 3
on release weeks
B. Use a needle and syringe to aspirate blood D. Try to discontinue cyclosporine (Neoral) as
from the fistula quickly as possible
C. Check for capillary refill of the nail beds on 40.  You suspect kidney transplant
that extremity
rejection when the patient shows which
D. Palpate the fistula throughout its length to
assess for a thrill symptoms?
35.  You have a paraplegic patient with A. Pain in the incision, general malaise, and
renal calculi. Which factor contributes to hypotension
the development of calculi? B. Pain in the incision, general malaise, and
depression
A. Increased calcium loss from the bones C. Fever, weight gain, and diminished urine
B. Decreased kidney function output
C. Decreased calcium intake D. Diminished urine output and hypotension
D. High fluid intake 41.  Your patient returns from the
36.  What is the most important nursing operating room after abdominal aortic
diagnosis for a patient in end-stage renal aneurysm repair. Which symptom is a
disease? sign of acute renal failure?
A. Risk for injury A. Anuria
B. Fluid volume excess B. Diarrhea
C. Altered nutrition: less than body requirements C. Oliguria
D. Activity intolerance D. Vomiting
37.  Frequent PVCs are noted on the 42.  Which cause of hypertension is the
cardiac monitor of a patient with end- most common in acute renal failure?
stage renal disease. The priority
intervention is: A. Pulmonary edema
B. Hypervolemia
A. Call the doctor immediately C. Hypovolemia
B. Give the patient IV lidocaine (Xylocaine) D. Anemia
C. Prepare to defibrillate the patient 43.  A patient returns from surgery with an
D. Check the patient’s latest potassium level indwelling urinary catheter in place and
38.  A patient who received a kidney empty. Six hours later, the volume is
transplant returns for a follow-up visit to 120ml. The drainage system has no
the outpatient clinic and reports a lump in obstructions. Which intervention has
her breast. Transplant recipients are: priority?
A. At increased risk for cancer due to A. Give a 500ml bolus of isotonic saline
immunosuppression caused by cyclosporine B. Evaluate the patient’s circulation and vital
(Neoral) signs
B. Consumed with fear after the life-threatening C. Flush the urinary catheter with sterile water or
experience of having a transplant saline
C. At increased risk for tumors because of the D. Place the patient in the shock position, and
kidney transplant notify the surgeon
D. At decreased risk for cancer, so the lump is
most likely benign
 44.  You’re preparing for urinary
catheterization of a trauma patient and
you observe bleeding at the urethral
meatus. Which action has priority?
A. Irrigate and clean the meatus before
catheterization
B. Check the discharge for occult blood before
catheterization
C. Heavily lubricate the catheter before insertion
D. Delay catheterization and notify the doctor
45.  What change indicates recovery in a
patient with nephritic syndrome?
A. Disappearance of protein from the urine
B. Decrease in blood pressure to normal
C. Increase in serum lipid levels
D. Gain in body weight
46.  Which statement correctly
distinguishes renal failure from prerenal
failure?
A. With prerenal failure, vasoactive substances
such as dopamine (Intropin) increase blood
pressure
B. With prerenal failure, there is less response to
such diuretics as furosemide (Lasix)
C. With prerenal failure, an IV isotonic saline
infusion increases urine output
D. With prerenal failure, hemodialysis reduces
the BUN level
47.  Which criterion is required before a
patient can be considered for continuous
peritoneal dialysis?
A. The patient must be hemodynamically stable
B. The vascular access must have healed
C. The patient must be in a home setting
D. Hemodialysis must have failed
48.  Polystyrene sulfonate (Kayexalate) is
used in renal failure to:
A. Correct acidosis
B. Reduce serum phosphate levels
C. Exchange potassium for sodium
D. Prevent constipation from sorbitol use
49.  Your patient has complaints of
severe right-sided flank pain, nausea,
vomiting and restlessness. He appears
slightly pale and is diaphoretic. Vital signs
are BP 140/90 mmHg, Pulse 118
beats/min., respirations 33
breaths/minute, and temperature, 98.0F.
Which subjective data supports a
diagnosis of renal calculi?
A. Pain radiating to the right upper quadrant
B. History of mild flu symptoms last week
C. Dark-colored coffee-ground emesis
D. Dark, scant urine output
50. Immunosuppression following Kidney
transplantation is continued:
A.  For life
B.  24 hours after transplantation
C.  A week after transplantation
D. Until the kidney is not anymore rejected
Answers and Rationales
1. B. Costovertebral angle tenderness, flank
pain, and chills are symptoms of acute
pyelonephritis. Jaundice indicates gallbladder
or liver obstruction. A burning sensation on
urination is a sign of lower urinary tract
infection.
2. B. A common symptom of a UTI is dysuria. A
patient with a UTI often reports frequent
voiding of small amounts and the urgency to
void. Urine that smells sweet is often
associated with diabetic ketoacidosis.
3. D. Pyridium is taken to relieve dysuria
because is provides an analgesic and
anesthetic effect on the urinary tract mucosa.
The patient can stop taking it after the dysuria
is relieved. The urine may temporarily turn
red or orange due to the dye in the drug. The
drug isn’t taken before voiding, and is usually
taken 3 times a day for 2 days.
4. C. Women are more prone to UTI’s after
menopause due to reduced estrogen levels.
Reduced estrogen levels lead to reduced levels
of vaginal Lactobacillibacteria, which protect
against infection. Angina, asthma and
fractures don’t increase the risk of UTI.
5. A. Tubing problems are a common cause of
outflow difficulties, check the tubing for kinks
and ensure that all clamps are open. Other
measures include having the patient change
positions (moving side to side or sitting up),
applying gentle pressure over the abdomen, or
having a bowel movement.
6. A. Dialysate should be infused quickly. The
dialysate should be infused over 15 minutes or
less when performing peritoneal dialysis. The
fluid exchange takes place over a period
ranging from 30 minutes to several hours.
7. B. Don’t take blood pressure readings in the
arm with the fistula because the compression
could damage the fistula. IV lines shouldn’t
 be inserted in the arm used for hemodialysis.
Palpate pulses below the fistula. Lack of bruit
or thrill should be reported to the doctor.
8. B. Disequilibrium syndrome is caused by a
rapid reduction in urea, sodium, and other
solutes from the blood. This can lead to
cerebral edema and increased intracranial
pressure (ICP). Signs and symptoms include
headache, nausea, restlessness, vomiting,
confusion, twitching, and seizures.
9. B. Treatment includes administering normal
saline or hypertonic normal saline solution
because muscle cramps can occur when the
sodium and water are removed to quickly
during dialysis. Reducing the rate of dialysis,
not increasing it, may alleviate muscle
cramps.
10.D. Calcium-phosphate deposits in the skin
may cause pruritus. Scratching leads to
excoriation and breaks in the skin that
increase the patient’s risk of infection.
Keeping fingernails short and clean helps
reduce the risk of infection.
11.D. All urine should be strained through gauze
or a urine strainer to catch stones that are
passed. The stones are then analyzed for
composition. Ambulation may help the
movement of the stone down the urinary tract.
Encourage fluid to help flush the stones out.
12.C. The most common form of acute
glomerulonephritis is caused by goup A beta-
hemolytic streptococcal infection elsewhere in
the body.
13.A. Narcotic analgesics are usually needed to
relieve the severe pain of renal calculi. Muscle
relaxants are typically used to treat skeletal
muscle spasms. NSAIDS and salicylates are
used for their anti-inflammatory and
antipyretic properties and to treat less severe
pain.
14.C. Invasive procedures such as catheterization
can introduce bacteria into the urinary tract. A
lack of fluid intake could cause concentration
of urine, but wouldn’t necessarily cause
infection.
15.C. Hematuria and proteinuria indicate acute
glomerulonephritis. These finding result from
increased permeability of the glomerular
membrane due to the antigen-antibody
reaction. Generalized edema is seen most
often in nephrosis.
16.B. Oliguria is defined as urine output of less
than 400ml/24hours.
17.B. Increased BUN is usually an early indicator
of decreased renal function.
18.C. Stress incontinence is an involuntary loss
of a small amount of urine due to sudden
increased intra-abdominal pressuer, such as
with coughing or sneezing.
19.B. Hemorrhage is a potential complication.
Urine retention isn’t a problem soon after
surgery because a catheter is in place.
Pneumonia may occur if the patient doesn’t
cough and deep breathe. Thrombosis may
occur later if the patient doesn’t ambulate.
20.D. An elevated prostate-specific antigen level
indicates prostate cancer, but it can be falsely
elevated if done after the prostate gland is
manipulated. A digital rectal examination
should be done as part of the yearly screening,
and then the antigen test is done if the digital
exam suggests cancer. MRI is used in staging
the cancer.
21.D. Kidney damage is still a concern.
Microavascular changes occur in both of the
patient’s kidneys as a complication of the
diabetes. Diabetic nephropathy is the leading
cause of end-stage renal disease. The kidneys
continue to produce urine until the end stage.
Nephropathy occurs even with insulin
management.
22.D. Drinking 2-3L of water daily inhibits
bacterial growth in the bladder and helps flush
the bacteria from the bladder. The patient
should be instructed to void after sexual
activity.
23.A. The drug turns the urine orange. It may be
prescribed for longer than 7 days and is
usually ordered three times a day after meals.
Phenazopyridine is an azo (nitrogenous)
analgesic; not an antibiotic.
24.C. Mild to moderate HTN may result from
sodium or water retention and inappropriate
rennin release from the kidneys. Oliguria and
fatigue also may be seen. Other signs are
proteinuria and azotemia.
25.B. Fluid volume excess because the kidneys
aren’t removing fluid and wastes. The other
diagnoses may apply, but they don’t take
priority.
26.A. Apply pressure when discontinuing
hemodialysis and after removing the
venipuncture needle until all the bleeding has
stopped. Bleeding may continue for 10
minutes in some patients.
27.B.
28.A. Daily doubling of the urine output
indicates that the nephrons are healing. This
means the patient is passing into the second
phase (dieresis) of acute renal failure.
29.D. Pressure on the fistula or the extremity can
decrease blood flow and precipitate clotting,
so avoid taking blood pressure on the affected
arm.
30.B. The patient should follow a low-protein
diet with a prescribed amount of water. The
patient requires some protein to meet
metabolic needs. Salt substitutes shouldn’t be
used without a doctor’s order because it may
contain potassium, which could make the
patient hyperkalemic. Fluid and protein
restrictions are needed.
31.A. Disequilibrium occurs when excess solutes
are cleared from the blood more rapidly than
they can diffuse from the body’s cells into the
vascular system.
32.B. Instruct the patient with neurogenic bladder
to write down his voiding pattern and empty
the bladder at the same times each day.
33.C. Because of damage to the nephrons, the
kidney can’t excrete all the metabolic wastes
of protein, so this patient’s protein intake must
be restricted. A higher intake of carbs, fats,
and vitamin supplements is needed to ensure
the growth and maintenance of the patient’s
tissues.
34.D. The vibration or thrill felt during palpation
ensures that the fistula has the desired
turbulent blood flow. Pinching the fistula
could cause damage. Aspirating blood is a
needless invasive procedure.
35.A. Bones lose calcium when a patient can no
longer bear weight. The calcium lost from
bones form calculi, a concentration of mineral
salts also known as a stone, in the renal
system.
36.B. Kidneys are unable to rid the body of
excess fluids which results in fluid volume
excess during ESRD.
37.D. The patient with ESRD may develop
arrhythmias caused by hypokalemi. Call the
doctor after checking the patient’s potassium
values. Lidocaine may be ordered if the PVCs
are frequent and the patient is symptomatic.
38. A. Cyclosporine suppresses the immune
response to prevent rejection of the
transplanted kidney. The use of cyclosporine
places the patient at risk for tumors.
39.A. The immunosuppressive activity of
cyclosporine places the patient at risk for
infection, and steroids can mask the signs of
infection. The patient may not be able to
resume normal fluid intake or return to work
for an extended period of time and the patient
may need cyclosporine therapy for life.
40.C. Symptoms of rejection include fever, rapid
weight gain, hypertension, pain over the graft
site, peripheral edema, and diminished urine
output.
41.C. Urine output less than 50ml in 24 hours
signifies oliguria, an early sign of renal
failure. Anuria is uncommon except in
obstructive renal disorders.
42.B. Acute renal failure causes hypervolemia as
a result of overexpansion of extracellular fluid
and plasma volume with the hypersecretion of
rennin. Therefore, hypervolemia causes
hypertension.
43.B. A total UO of 120ml is too low. Assess the
patient’s circulation and hemodynamic
stability for signs of hypovolemia. A fluid
bolus may be required, but only after further
nursing assessment and a doctor’s order.
44.D. Bleeding at the urethral meatus is evidence
that the urethra is injured. Because
catheterization can cause further harm, consult
with the doctor.
45.A. With nephrotic syndrome, the glomerular
basement membrane of the kidney becomes
more porous, leading to loss of protein in the
urine. As the patient recovers, less protein is
found in the urine.
46.C. Prerenal failure is caused by such
conditions as hypovolemia that impairs
kidney perfusion; giving isotonic fluids
improves urine output. Vasoactive substances
can increase blood pressure in both
conditions.
47.A. Hemodynamic stability must be established
before continuous peritoneal dialysis can be
started.
48.C. In renal failure, patients become
hyperkalemic because they can’t excrete
potassium in the urine. Polystyrene sulfonate
acts to excrete potassium by pulling potassium
into the bowels and exchanging it for sodium.
49.D. Patients with renal calculi commonly have
blood in the urine caused by the stone’s
passage through the urinary tract. The urine
appears dark, tests positive for blood, and is
typically scant.
50.A. For life.
 NCLEX Practice Exam for Respiratory System 1
1. The nurse is caring for a male client
with a chest tube. If the chest drainage
system is accidentally disconnected, what
should the nurse plan to do?
A. Place the end of the chest tube in a container
of sterile saline.
B. Apply an occlusive dressing and notify the
physician.
C. Clamp the chest tube immediately.
D. Secure the chest tube with tape.
2. A male elderly client is admitted to an
acute care facility with influenza. The
nurse monitors the client closely for
complications. What is the most common
complication of influenza?
A. Septicemia
B. Pneumonia
C. Meningitis
D. Pulmonary edema
3. A female client has a tracheostomy but
doesn’t require continuous mechanical
ventilation. When weaning the client from
the tracheostomy tube, the nurse initially
should plug the opening in the tube for:
A. 15 to 60 seconds.
B. 5 to 20 minutes.
C. 30 to 40 minutes.
D. 45 to 60 minutes.
4. Gina, a home health nurse is visiting a
home care client with advanced lung
cancer. Upon assessing the client, the
nurse discovers wheezing, bradycardia,
and a respiratory rate of 10
breaths/minute. These signs are
associated with which condition?
A. Hypoxia
B. Delirium
C. Hyperventilation
D. Semiconsciousness
5. A male client with Guillain-Barré
syndrome develops respiratory acidosis
as a result of reduced alveolar ventilation.
Which combination of arterial blood gas
(ABG) values confirms respiratory
acidosis?
A. pH, 5.0; PaCO2 30 mm Hg
B. pH, 7.40; PaCO2 35 mm Hg
C. pH, 7.35; PaCO2 40 mm Hg
D. pH, 7.25; PaCO2 50 mm Hg
6. A female client with interstitial lung
disease is prescribed prednisone
(Deltasone) to control inflammation.
During client teaching, the nurse stresses
the importance of taking prednisone
exactly as prescribed and cautions
against discontinuing the drug abruptly. A
client who discontinues prednisone
abruptly may experience:
A. hyperglycemia and glycosuria.
B. acute adrenocortical insufficiency.
C. GI bleeding.
D. restlessness and seizures.
7. A male client is admitted to the health
care facility for treatment of chronic
obstructive pulmonary disease. Which
nursing diagnosis is most important for
this client?
A. Activity intolerance related to fatigue
B. Anxiety related to actual threat to health status
C. Risk for infection related to retained
secretions
D. Impaired gas exchange related to airflow
obstruction
8. A male client abruptly sits up in bed,
reports having difficulty breathing and has
an arterial oxygen saturation of 88%.
Which mode of oxygen delivery would
most likely reverse the manifestations?
A. Simple mask
B. Non-rebreather mask
C. Face tent
D. Nasal cannula
9. A male adult client with cystic fibrosis is
admitted to an acute care facility with an
acute respiratory infection. Prescribed
respiratory treatment includes chest
physiotherapy. When should the nurse
perform this procedure?
A. Immediately before a meal
B. At least 2 hours after a meal
C. When bronchospasms occur
D. When secretions have mobilized
10. On arrival at the intensive care unit, a
critically ill female client suffers
 respiratory arrest and is placed on 15. Nurse Mickey is administering a
mechanical ventilation. The physician purified protein derivative (PPD) test to a
orders pulse oximetry to monitor the homeless client. Which of the following
client’s arterial oxygen saturation (SaO2) statements concerning PPD testing is
noninvasively. Which vital sign true?
abnormality may alter pulse oximetry
A. A positive reaction indicates that the client
values? has active tuberculosis (TB).
A. Fever B. A positive reaction indicates that the client
B. Tachypnea has been exposed to the disease.
C. Tachycardia C. A negative reaction always excludes the
D. Hypotension diagnosis of TB.
D. The PPD can be read within 12 hours after the
11. The nurse is caring for a male client
injection.
who recently underwent a tracheostomy.
16. Nurse Murphy administers albuterol
The first priority when caring for a client
(Proventil), as prescribed, to a client with
with a tracheostomy is:
emphysema. Which finding indicates that
A. helping him communicate. the drug is producing a therapeutic
B. keeping his airway patent. effect?
C. encouraging him to perform activities of daily
living. A. Respiratory rate of 22 breaths/minute
D. preventing him from developing an infection. B. Dilated and reactive pupils
12. For a male client with chronic C. Urine output of 40 ml/hour
D. Heart rate of 100 beats/minute
obstructive pulmonary disease, which
17. What is the normal pH range for
nursing intervention would help maintain
arterial blood?
a patent airway?
A. 7 to 7.49
A. Restricting fluid intake to 1,000 ml/day
B. 7.35 to 7.45
B. Enforcing absolute bed rest
C. 7.50 to 7.60
C. Teaching the client how to perform controlled
D. 7.55 to 7.65
coughing
D. Administering prescribed sedatives regularly 18. Before weaning a male client from a
and in large amounts ventilator, which assessment parameter is
13. The amount of air inspired and most important for the nurse to review?
expired with each breath is called: A. Fluid intake for the last 24 hours
A. tidal volume. B. Baseline arterial blood gas (ABG) levels
B. residual volume. C. Prior outcomes of weaning
C. vital capacity. D. Electrocardiogram (ECG) results
D. dead-space volume. 19. Which of the following would be most
14. A male client with pneumonia appropriate for a male client with an
develops respiratory failure and has a arterial blood gas (ABG) of pH 7.5,
partial pressure of arterial oxygen of 55 PaCO2 26 mm Hg, O2 saturation 96%,
mm Hg. He’s placed on mechanical HCO3 24 mEq/L, and PaO2 94 mm Hg?
ventilation with a fraction of inspired A. Administer a prescribed decongestant.
oxygen (FIO2) of 0.9. The nursing goal B. Instruct the client to breathe into a paper bag.
should be to reduce the FIO2 to no C. Offer the client fluids frequently.
greater than: D. Administer prescribed supplemental oxygen.
20. A female client is receiving
A. 0.21
supplemental oxygen. When determining
B. 0.35
C. 0.5 the effectiveness of oxygen therapy,
D. 0.7
 which arterial blood gas value is most
important?
A. pH
B. Bicarbonate (HCO3–)
C. Partial pressure of arterial oxygen (PaO2)
D. Partial pressure of arterial carbon dioxide
(PaCO2)
21. Nurse Julia is caring for a client who
has a tracheostomy and temperature of
103° F (39.4° C). Which of the following
interventions will most likely lower the
client’s arterial blood oxygen saturation?
A. Endotracheal suctioning
B. Encouragement of coughing
C. Use of cooling blanket
D. Incentive spirometry
22. For a male client who has a chest
tube connected to a closed water-seal
drainage system, the nurse should
include which action in the plan of care?
A. Measuring and documenting the drainage in
the collection chamber
B. Maintaining continuous bubbling in the water-
seal chamber
C. Keeping the collection chamber at chest level
D. Stripping the chest tube every hour
23. Nurse Eve formulates a nursing
diagnosis of Activity intolerance related to
inadequate oxygenation and dyspnea for
a client with chronic bronchitis. To
minimize this problem, the nurse instructs
the client to avoid conditions that increase
oxygen demands. Such conditions
include:
A. drinking more than 1,500 ml of fluid daily.
B. being overweight.
C. eating a high-protein snack at bedtime.
D. eating more than three large meals a day.
24. A black male client with asthma seeks
emergency care for acute respiratory
distress. Because of this client’s dark
skin, the nurse should assess for
cyanosis by inspecting the:
A. lips.
B. mucous membranes.
C. nail beds.
D. earlobes.
25. A female client with asthma is
receiving a theophylline preparation to
promote bronchodilation. Because of the
risk of drug toxicity, the nurse must
monitor the client’s serum theophylline
level closely. The nurse knows that the
therapeutic theophylline concentration
falls within which range?
A. 1 to 2 mcg/ml
B. 2 to 5 mcg/ml
C. 5 to 10 mcg/ml
D. 10 to 20 mcg/ml
26. A male client is to receive I.V.
vancomycin (Vancocin). When preparing
to administer this drug, the nurse should
keep in mind that:
A. vancomycin should be infused over 60 to 90
minutes in a large volume of fluid.
B. vancomycin may cause irreversible
neutropenia.
C. vancomycin should be administered rapidly in
a large volume of fluid.
D. vancomycin should be administered over 1 to
2 minutes as an I.V. bolus.
27. Before seeing a newly assigned
female client with respiratory alkalosis,
the nurse quickly reviews the client’s
medical history. Which condition is a
predisposing factor for respiratory
alkalosis?
A. Myasthenia gravis
B. Type 1 diabetes mellitus
C. Extreme anxiety
D. Narcotic overdose
28. At 11 p.m., a male client is admitted to
the emergency department. He has a
respiratory rate of 44 breaths/minute.
He’s anxious, and wheezes are audible.
The client is immediately given oxygen by
face mask and methylprednisolone
(Depo-medrol) I.V. At 11:30 p.m., the
client’s arterial blood oxygen saturation is
86% and he’s still wheezing. The nurse
should plan to administer:
A. alprazolam (Xanax).
B. propranolol (Inderal)
C. morphine.
D. albuterol (Proventil).
 29. Pulmonary disease (COPD), which
nursing action best promotes adequate
gas exchange?
A. Encouraging the client to drink three glasses
of fluid daily
B. Keeping the client in semi-Fowler’s position
C. Using a high-flow Venturi mask to deliver
oxygen as prescribed
D. Administering a sedative as prescribed
30. Nurse Joana is teaching a client with
emphysema how to perform pursed-lip
breathing. The client asks the nurse to
explain the purpose of this breathing
technique. Which explanation should the
nurse provide?
A. It helps prevent early airway collapse.
B. It increases inspiratory muscle strength
C. It decreases use of accessory breathing
muscles.
D. It prolongs the inspiratory phase of
respiration.
Answers and Rationales
1. Answer A. If a chest drainage system is
disconnected, the nurse may place the end of
the chest tube in a container of sterile saline or
water to prevent air from entering the chest
tube, thereby preventing negative respiratory
pressure. The nurse should apply an occlusive
dressing if the chest tube is pulled out — not
if the system is disconnected. The nurse
shouldn’t clamp the chest tube because
clamping increases the risk of tension
pneumothorax. The nurse should tape the
chest tube securely to prevent it from being
disconnected, rather than taping it after it has
been disconnected.
2. Answer B. Pneumonia is the most common
complication of influenza. It may be either
primary influenza viral pneumonia or
pneumonia secondary to a bacterial infection.
Other complications of influenza include
myositis, exacerbation of chronic obstructive
pulmonary disease, and Reye’s syndrome.
Myocarditis, pericarditis, transverse myelitis,
and encephalitis are rare complications of
influenza. Although septicemia may arise
when any infection becomes overwhelming, it
rarely results from influenza. Meningitis and
pulmonary edema aren’t associated with
influenza.
3. Answer B. Initially, the nurse should plug the
opening in the tracheostomy tube for 5 to 20
minutes, and then gradually lengthen this
interval according to the client’s respiratory
status. A client who doesn’t require
continuous mechanical ventilation already is
breathing without assistance, at least for short
periods; therefore, plugging the opening of the
tube for only 15 to 60 seconds wouldn’t be
long enough to reveal the client’s true
tolerance to the procedure. Plugging the
opening for more than 20 minutes would
increase the risk of acute respiratory distress
because the client requires an adjustment
period to start breathing normally.
4. Answer A. As the respiratory center in the
brain becomes depressed, hypoxia occurs,
producing wheezing, bradycardia, and a
decreased respiratory rate. Delirium is a state
of mental confusion characterized by
disorientation to time and place.
Hyperventilation (respiratory rate greater than
that metabolically necessary for gas
exchange) is marked by an increased
respiratory rate or tidal volume, or both.
Semiconsciousness is a state of impaired
consciousness characterized by limited motor
and verbal responses and decreased
orientation.
5. Answer D. In respiratory acidosis, ABG
analysis reveals an arterial pH below 7.35 and
partial pressure of arterial carbon dioxide
(PaCO2) above 45 mm Hg. Therefore, the
combination of a pH value of 7.25 and a
PaCO2 value of 50 mm Hg confirms
respiratory acidosis. A pH value of 5.0 with a
PaCO2 value of 30 mm Hg indicates
respiratory alkalosis. Options B and C
represent normal ABG values, reflecting
normal gas exchange in the lungs.
6. Answer B. Administration of a corticosteroid
such as prednisone suppresses the body’s
natural cortisol secretion, which may take
weeks or months to normalize after drug
discontinuation. Abruptly discontinuing such
therapy may cause the serum cortisol level to
drop low enough to trigger acute
adrenocortical insufficiency. Hyperglycemia,
glycosuria, GI bleeding, restlessness, and
seizures are common adverse effects of
corticosteroid therapy, not its sudden
cessation.
7. Answer D. A patent airway and an adequate
breathing pattern are the top priority for any
client, making impaired gas exchange related
to airflow obstruction the most important
 nursing diagnosis. The other options also may
apply to this client but are less important.
8. Answer B. A non-rebreather mask can deliver
levels of the fraction of inspired oxygen
(FIO2) as high as 100%. Other modes —
simple mask, face tent and nasal cannula —
deliver lower levels of FIO2.
9. Answer B. The nurse should perform chest
physiotherapy at least 2 hours after a meal to
reduce the risk of vomiting and aspiration.
Performing it immediately before a meal may
tire the client and impair the ability to eat.
Percussion and vibration, components of chest
physiotherapy, may worsen bronchospasms;
therefore, the procedure is contraindicated in
clients with bronchospasms. Secretions that
have mobilized (especially when suction
equipment isn’t available) are a
contraindication for postural drainage, another
component of chest physiotherapy.
10.Answer D. Hypotension, hypothermia, and
vasoconstriction may alter pulse oximetry
values by reducing arterial blood flow.
Likewise, movement of the finger to which
the oximeter is applied may interfere with
interpretation of SaO2. All of these conditions
limit the usefulness of pulse oximetry. Fever,
tachypnea, and tachycardia don’t affect pulse
oximetry values directly.
11.Answer B. Maintaining a patent airway is the
most basic and critical human need. All other
interventions are important to the client’s
well-being but not as important as having
sufficient oxygen to breathe.
12.Answer C. Controlled coughing helps
maintain a patent airway by helping to
mobilize and remove secretions. A moderate
fluid intake (usually 2 L or more daily) and
moderate activity help liquefy and mobilize
secretions. Bed rest and sedatives may limit
the client’s ability to maintain a patent airway,
causing a high risk of infection from pooled
secretions.
13.Answer A. Tidal volume is the amount of air
inspired and expired with each breath.
Residual volume is the amount of air
remaining in the lungs after forcibly exhaling.
Vital capacity is the maximum amount of air
that can be moved out of the lungs after
maximal inspiration and expiration. Dead-
space volume is the amount of air remaining
in the upper airways that never reaches the
alveoli. In pathologic conditions, dead space
may also exist in the lower airways.
14.Answer C. An FO2 greater than 0.5 for as
little as 16 to 24 hours can be toxic and can
lead to decreased gas diffusion and surfactant
activity. The ideal oxygen source is room air
F IO 2 0.18 to 0.21.
15.Answer B. A positive reaction means the
client has been exposed to TB; it isn’t
conclusive of the presence of active disease. A
positive reaction consists of palpable swelling
and induration of 5 to 15 mm. It can be read
48 to 72 hours after the injection. In clients
with positive reactions, further studies are
usually done to rule out active disease. In
immunosuppressed clients, a negative reaction
doesn’t exclude the presence of active disease.
16.Answer A. In a client with emphysema,
albuterol is used as a bronchodilator. A
respiratory rate of 22 breaths/minute indicates
that the drug has achieved its therapeutic
effect because fewer respirations are required
to achieve oxygenation. Albuterol has no
effect on pupil reaction or urine output. It may
cause a change in the heart rate, but this is an
adverse, not therapeutic, effect.
17.Answer B. A pH less than 7.35 is indicative
of acidosis; a pH above 7.45 indicates
alkalosis.
18.Answer B. Before weaning a client from
mechanical ventilation, it’s most important to
have baseline ABG levels. During the
weaning process, ABG levels will be checked
to assess how the client is tolerating the
procedure. Other assessment parameters are
less critical. Measuring fluid volume intake
and output is always important when a client
is being mechanically ventilated. Prior
attempts at weaning and ECG results are
documented on the client’s record, and the
nurse can refer to them before the weaning
process begins.
19.Answer B. The ABG results reveal
respiratory alkalosis. The best intervention to
raise the PaCO2 level would be to have the
client breathe into a paper bag. All of the
other options — such as administering a
decongestant, offering fluids frequently, and
administering supplemental oxygen —
wouldn’t raise the lowered PaCO2 level.
20.Answer C. The most significant and direct
indicator of the effectiveness of oxygen
therapy is the PaO2 value. Based on the PaO2
value, the nurse may adjust the type of oxygen
delivery (cannula, venturi mask, or
mechanical ventilator), flow rate, and oxygen
 percentage. The other options reflect the
client’s ventilation status, not oxygenation.
21.Answer A. Endotracheal suctioning removes
secretions as well as gases from the airway
and lowers the arterial oxygen saturation
(SaO2) level. Coughing and incentive
spirometry improves oxygenation and should
raise or maintain oxygen saturation. Because
of superficial vasoconstriction, using a
cooling blanket can lower peripheral oxygen
saturation readings, but SaO2 levels wouldn’t
be affected.
22.Answer A. The nurse should measure and
document the amount of chest tube drainage
regularly to detect abnormal drainage patterns,
such as may occur with a hemorrhage (if
excessive) or a blockage (if decreased).
Continuous bubbling in the water-seal
chamber indicates a leak in the closed chest
drainage system, which must be corrected.
The nurse should keep the collection chamber
below chest level to allow fluids to drain into
it. The nurse should not strip chest tubes
because doing so may traumatize the tissue or
dislodge the tube.
23.Answer B. Conditions that increase oxygen
demands include obesity, smoking, exposure
to temperature extremes, and stress. A client
with chronic bronchitis should drink at least
2,000 ml of fluid daily to thin mucus
secretions; restricting fluid intake may be
harmful. The nurse should encourage the
client to eat a high-protein snack at bedtime
because protein digestion produces an amino
acid with sedating effects that may ease the
insomnia associated with chronic bronchitis.
Eating more than three large meals a day may
cause fullness, making breathing
uncomfortable and difficult; however, it
doesn’t increase oxygen demands. To help
maintain adequate nutritional intake, the client
with chronic bronchitis should eat small,
frequent meals (up to six a day).
24.Answer B. Skin color doesn’t affect the
mucous membranes. The lips, nail beds, and
earlobes are less reliable indicators of
cyanosis because they’re affected by skin
color.
25.Answer D. The therapeutic serum
theophylline concentration ranges from 10 to
20 mcg/ml. Values below 10 mcg/ml aren’t
therapeutic.
26.Answer A. To avoid a hypotensive reaction
from rapid I.V. administration, the nurse
should infuse vancomycin slowly, over 60 to
90 minutes, in a large volume of fluid.
Although neutropenia may occur in
approximately 5% to 10% of clients receiving
vancomycin, this adverse effect reverses
rapidly when the drug is discontinued.
27.Answer C. Extreme anxiety may lead to
respiratory alkalosis by causing
hyperventilation, which results in excessive
carbon dioxide (CO2) loss. Other conditions
that may set the stage for respiratory alkalosis
include fever, heart failure, and injury to the
brain’s respiratory center, overventilation with
a mechanical ventilator, pulmonary embolism,
and early salicylate intoxication. Type 1
diabetes mellitus may lead to diabetic
ketoacidosis; the deep, rapid respirations
occurring in this disorder (Kussmaul’s
respirations) don’t cause excessive CO2 loss.
Myasthenia gravis and narcotic overdose
suppress the respiratory drive, causing CO2
retention, not CO2 loss; this may lead to
respiratory acidosis, not alkalosis.
28.Answer D. The client is hypoxemic because
of bronchoconstriction as evidenced by
wheezes and a subnormal arterial oxygen
saturation level. The client’s greatest need is
bronchodilation, which can be accomplished
by administering bronchodilators. Albuterol is
a beta2 adrenergic agonist, which causes
dilation of the bronchioles. It’s given by
nebulization or metered-dose inhalation and
may be given as often as every 30 to 60
minutes until relief is accomplished.
Alprazolam is an anxiolytic and central
nervous system depressant, which could
suppress the client’s breathing. Propranolol is
contraindicated in a client who’s wheezing
because it’s a beta2 adrenergic antagonist.
Morphine is a respiratory center depressant
and is contraindicated in this situation.
29.Answer C. The client with COPD retains
carbon dioxide, which inhibits stimulation of
breathing by the medullary center in the brain.
As a result, low oxygen levels in the blood
stimulate respiration, and administering
unspecified, unmonitored amounts of oxygen
may depress ventilation. To promote adequate
gas exchange, the nurse should use a Venturi
mask to deliver a specified, controlled amount
of oxygen consistently and accurately.
Drinking three glasses of fluid daily wouldn’t
affect gas exchange or be sufficient to liquefy
secretions, which are common in COPD.
Clients with COPD and respiratory distress
should be placed in high Fowler’s position
 and shouldn’t receive sedatives or other drugs
that may further depress the respiratory
center.
30.Answer A. Pursed-lip breathing helps prevent
early airway collapse. Learning this technique
helps the client control respiration during
periods of excitement, anxiety, exercise, and
respiratory distress. To increase inspiratory
muscle strength and endurance, the client may
need to learn inspiratory resistive breathing.
To decrease accessory muscle use and thus
reduce the work of breathing, the client may
need to learn diaphragmatic (abdominal)
breathing. In pursed-lip breathing, the client
mimics a normal inspiratory-expiratory (I:E)
ratio of 1:2. (A client with emphysema may
have an I:E ratio as high as 1:4.)
 NCLEX Practice Exam for Respiratory System 2
1. A male client who takes theophylline
for chronic obstructive pulmonary disease
is seen in the urgent care center for
respiratory distress. Once the client is
stabilized, the nurse begins discharge
teaching. The nurse would be especially
vigilant to include information about
complying with medication therapy if the
client’s baseline theophylline level was:
A. 10 mcg/mL
B. 12 mcg/mL
C. 15 mcg/mL
D. 18mcg/mL
2. Nurse Kim is caring for a client with a
pneumothorax and who has had a chest
tube inserted notes continuous gentle
bubbling in the suction control chamber.
What action is appropriate?
A. Do nothing, because this is an expected
finding.
B. Immediately clamp the chest tube and notify
the physician.
C. Check for an air leak because the bubbling
should be intermittent.
D. Increase the suction pressure so that bubbling
becomes vigorous.
3. A nurse has assisted a physician with
the insertion of a chest tube. The nurse
monitors the adult client and notes
fluctuation of the fluid level in the water
seal chamber after the tube is inserted.
Based on this assessment, which action
would be appropriate?
A. Inform the physician.
B. Continue to monitor the client.
C. Reinforce the occlusive dressing.
D. Encourage the client to deep-breathe.
4. The nurse caring for a male client with
a chest tube turns the client to the side,
and the chest tube accidentally
disconnects. The initial nursing action is
to:
A. Call the physician.
B. Place the tube in a bottle of sterile water.
C. Immediately replace the chest tube system.
D. Place the sterile dressing over the
disconnection site.
5. Nurse Paul is assisting a physician with
the removal of a chest tube. The nurse
should instruct the client to:
A. Exhale slowly.
B. Stay very still.
C. Inhale and exhale quickly.
D. Perform the Valsalva maneuver.
6. While changing the tapes on a
tracheostomy tube, the male client
coughs and the tube is dislodged. The
initial nursing action is to:
A. Call the physician to reinsert the tube.
B. Grasp the retention sutures to spread the
opening.
C. Call the respiratory therapy department to
reinsert the tracheotomy.
D. Cover the tracheostomy site with a sterile
dressing to prevent infection.
7. A nurse is caring for a male client
immediately after removal of the
endotracheal tube. The nurse reports
which of the following signs immediately if
experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate of 24 breaths/min
8. An emergency room nurse is assessing
a female client who has sustained a blunt
injury to the chest wall. Which of these
signs would indicate the presence of a
pneumothorax in this client?
A. A low respiratory
B. Diminished breathe sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury
9. A nurse is caring for a male client
hospitalized with acute exacerbation of
chronic obstructive pulmonary disease.
Which of the following would the nurse
expect to note on assessment of this
client?
A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increase oxygen saturation with exercise
D. A widened diaphragm noted on the chest x-
ray
 10. A community health nurse is
conducting an educational session with
community members regarding
tuberculosis. The nurse tells the group
that one of the first symptoms associated
with tuberculosis is:
C. Strengthen the intercostal muscles.
D. Promote carbon dioxide elimination.
15. Nurse Hannah is preparing to obtain a
sputum specimen from a client. Which of
the following nursing actions will facilitate
obtaining the specimen?

A. Dyspnea A. Limiting fluids

B. Chest pain B. Having the clients take three deep breaths
C. A bloody, productive cough C. Asking the client to split into the collection
D. A cough with the expectoration of mucoid container
sputum D. Asking the client to obtain the specimen after
eating
11. A nurse performs an admission
16. A nurse is caring for a female client
assessment on a female client with a
after a bronchoscope and biopsy. Which
diagnosis of tuberculosis. The nurse
of the following signs, if noted in the
reviews the results of which diagnostic
client, should be reported immediately to
test that will confirm this diagnosis?
the physicians?
A. Bronchoscopy
B. Sputum culture A. Dry cough
C. Chest x-ray B. Hematuria
D. Tuberculin skin test C. Bronchospasm
D. Blood-streaked sputum
12. The nursing instructor asks a nursing
17. A nurse is suctioning fluids from a
student to describe the route of
male client via a tracheostomy tube.
transmission of tuberculosis. The
When suctioning, the nurse must limit the
instructor concludes that the student
suctioning time to a maximum of:
understands this information if the student
states that the tuberculosis is transmitted A. 1 minute
by: B. 5 seconds
C. 10 seconds
A. Hand and mouth D. 30 seconds
B. The airborne route 18. A nurse is suctioning fluids from a
C. The fecal-oral route
female client through an endotracheal
D. Blood and body fluids
tube. During the suctioning procedure, the
13. A nurse is caring for a male client with
nurse notes on the monitor that the heart
emphysema who is receiving oxygen. The
rate is decreasing. Which of the following
nurse assesses the oxygen flow rate to
is the appropriate nursing intervention?
ensure that it does not exceed:
A. Continue to suction.
A. 1 L/min
B. Notify the physician immediately.
B. 2 L/min
C. Stop the procedure and reoxygenate the client.
C. 6 L/min
D. Ensure that the suction is limited to 15
D. 10 L/min
seconds.
14. A nurse instructs a female client to
19. An unconscious male client is
use the pursed-lip method of breathing
admitted to an emergency room. Arterial
and the client asks the nurse about the
blood gas measurements reveal a pH of
purpose of this type of breathing. The
7.30, a low bicarbonate level, a normal
nurse responds, knowing that the primary
carbon dioxide level, a normal oxygen
purpose of pursed-lip breathing is to:
level, and an elevated potassium level.
A. Promote oxygen intake. These results indicate the presence of:
B. Strengthen the diaphragm.
A. Metabolic acidosis A. Cyanosis
B. Respiratory acidosis B. Hypotension
C. Overcompensated respiratory acidosis C. Paradoxical chest movement
D. Combined respiratory and metabolic acidosis D. Dyspnea, especially on exhalation
20. A female client is suspected of having 25. A male client has been admitted with
a pulmonary embolus. A nurse assesses chest trauma after a motor vehicle
the client, knowing that which of the accident and has undergone subsequent
following is a common clinical intubation. A nurse checks the client
manifestation of pulmonary embolism? when the high-pressure alarm on the
ventilator sounds, and notes that the
A. Dyspnea
B. Bradypnea client has absence of breathe sounds in
C. Bradycardia right upper lobe of the lung. The nurse
D. Decreased respiratory immediately assesses for other signs of:
21. A nurse teaches a male client about
A. Right pneumothorax
the use of a respiratory inhaler. Which B. Pulmonary embolism
action by the client indicates a need for C. Displaced endotracheal tube
further teaching? D. Acute respiratory distress syndrome
26. A nurse is teaching a male client with
A. Inhales the mist and quickly exhales
B. Removes the cap and shakes the inhaler well chronic respiratory failure how to use a
before use metered-dose inhaler correctly. The nurse
C. Presses the canister down with the finger as he instructs the client to:
breathes in
D. Waits 1 to 2 minutes between puffs if more A. Inhale quickly
than one puff has been prescribed B. Inhale through the nose
C. Hold the breath after inhalation
22. A female client has just returned to a
D. Take two inhalations during one breath
nursing unit following bronchoscopy. A
27. A nurse is assessing a female client
nurse would implement which of the
with multiple trauma who is at risk for
following nursing interventions for this
developing acute respiratory distress
client?
syndrome. The nurse assesses for which
A. Administering atropine intravenously earliest sign of acute respiratory distress
B. Administering small doses of midazolam syndrome?
(Versed)
C. Encouraging additional fluids for the next 24 A. Bilateral wheezing
hours B. Inspiratory crackles
D. Ensuring the return of the gag reflex before C. Intercostal retractions
offering food or fluids D. Increased respiratory rate
23. A nurse is assessing the respiratory 28. A nurse is taking pulmonary artery
status of a male client who has suffered a catheter measurements of a male client
fractured rib. The nurse would expect to with acute respiratory distress syndrome.
note which of the following? The pulmonary capillary wedge pressure
reading is 12mm Hg. The nurse interprets
A. Slow deep respirations that this readings is:
B. Rapid deep respirations
C. Paradoxical respirations A. High and expected
D. Pain, especially with inspiration B. Low and unexpected
24. A female client with chest injury has C. Normal and expected
suffered flail chest. A nurse assesses the D. Uncertain and unexpected
client for which most distinctive sign of 29. A nurse is assessing a male client
flail chest? with chronic airflow limitations and notes
that the client has a “barrel chest.” The
 nurse interprets that this client has which
of the following forms of chronic airflow
limitations?
A. Emphysema
B. Bronchial asthma
C. Chronic obstructive bronchitis
D. Bronchial asthma and bronchitis
30. A nurse is caring for a female client
diagnosed with tuberculosis. Which
assessment, if made by the nurse, is
inconsistent with the usual clinical
presentation of tuberculosis and may
indicate the development of a concurrent
problem?
A. Cough
B. High-grade fever
C. Chills and night sweats
D. Anorexia and weight loss
Answers and Rationales
1. Answer A. The therapeutic range for the
serum theophylline level is 10 to 20 mcg/mL.
If the level is below the therapeutic range, the
client may experience frequent exacerbations
of the disorder. Although all the options
identify values within the therapeutic range,
option A is the option that reflects a need for
compliance with medication.
2. Answer A. Continuous gentle bubbling
should be noted in the suction control
chamber. Option B is incorrect. Chest tubes
should only be clamped to check for an air
leak or when changing drainage devices
(according to agency policy). Option C is
incorrect. Bubbling should be continuous and
not intermittent. Option D is incorrect because
bubbling should be gentle. Increasing the
suction pressure only increases the rate of
evaporation of water in the drainage system.
3. Answer B. The presence of fluctuation of the
fluid level in the water seal chamber indicates
a patent drainage system. With normal
breathing, the water level rises with
inspiration and falls with expiration.
Fluctuation stops if the tube is obstructed, if a
dependent loop exists, if the suction is not
working properly, or if the lung has
reexpanded. Options A, C, and D are
incorrect.
4. Answer B. If the chest drainage system is
disconnected, the end of the tube is placed in a
bottle of sterile water held below the level of
the chest. The system is replaced if it breaks
or cracks or if the collection chamber is full.
Placing a sterile dressing over the
disconnection site will not prevent
complications resulting from the
disconnection. The physician may need to be
notified, but this is not the initial action.
5. Answer D. When the chest tube is removed,
the client is asked to perform the Valsalva
maneuver (take a deep breath, exhale, and
bear down). The tube is quickly withdrawn,
and an airtight dressing is taped in place. An
alternative instruction is to ask the client to
take a deep breath and hold the breath while
the tube is removed. Options A, B, and C are
incorrect client instructions.
6. Answer B. If the tube is dislodged
accidentally, the initial nursing action is to
grasp the retention sutures and spread the
opening. If agency policy permits, the nurse
then attempts immediately to replace the tube.
Covering the tracheostomy site will block the
airway. Options 1 and 3 will delay treatment
in this emergency situation.
7. Answer A. The nurse reports stridor to the
physician immediately. This is a high-pitched,
coarse sound that is heard with the
stethoscope over the trachea. Stridor indicates
airway edema and places the client at risk for
airway obstruction. Options B, C, and D are
not signs that require immediate notification
of the physician.
8. Answer B. This client has sustained a blunt or
a closed chest injury. Basic symptoms of a
closed pneumothorax are shortness of breath
and chest pain. A larger pneumothorax may
cause tachypnea, cyanosis, diminished breath
sounds, and subcutaneous emphysema.
Hyperresonance also may occur on the
affected side. A sucking sound at the site of
injury would be noted with an open chest
injury.
9. Answer B. Clinical manifestations of chronic
obstructive pulmonary disease (COPD)
include hypoxemia, hypercapnia, dyspnea on
exertion and at rest, oxygen desaturation with
exercise, and the use of accessory muscles of
respiration. Chest x-rays reveal a
hyperinflated chest and a flattened diaphragm
if the disease is advanced.
10.Answer D. One of the first pulmonary
symptoms is a slight cough with the
expectoration of mucoid sputum. Options A,
B, and C are late symptoms and signify
cavitation and extensive lung involvement.
11.Answer B. Tuberculosis is definitively
diagnosed through culture and isolation of
Mycobacterium tuberculosis. A presumptive
diagnosis is made based on a tuberculin skin
test, a sputum smear that is positive for acid-
fast bacteria, a chest x-ray, and histological
evidence of granulomatous disease on biopsy.
12.Answer B. Tuberculosis is an infectious
disease caused by the bacillus Mycobacterium
tuberculosis and is spread primarily by the
airborne route. Options A, C, and D are
incorrect.
13.Answer B. Oxygen is used cautiously and
should not exceed 2 L/min. Because of the
long-standing hypercapnia that occurs in
emphysema, the respiratory drive is triggered
by low oxygen levels rather than increased
carbon dioxide levels, as is the case in a
normal respiratory system.
14.Answer D. Pursed-lip breathing facilitates
maximal expiration for clients with
obstructive lung disease. This type of
breathing allows better expiration by
increasing airway pressure that keeps air
passages open during exhalation. Options A,
B, and C are not the purposes of this type of
breathing.
15.Answer B. To obtain a sputum specimen, the
client should rinse the mouth to reduce
contamination, breathe deeply, and then
cough into a sputum specimen container. The
client should be encouraged to cough and not
spit so as to obtain sputum. Sputum can be
thinned by fluids or by a respiratory treatment
such as inhalation of nebulized saline or
water. The optimal time to obtain a specimen
is on arising in the morning.
16.Answer C. If a biopsy was performed during
a bronchoscopy, blood-streaked sputum is
expected for several hours. Frank blood
indicates hemorrhage. A dry cough may be
expected. The client should be assessed for
signs of complications, which would include
cyanosis, dyspnea, stridor, bronchospasm,
hemoptysis, hypotension, tachycardia, and
dysrhythmias. Hematuria is unrelated to this
procedure.
17.Answer C. Hypoxemia can be caused by
prolonged suctioning, which stimulates the
pacemaker cells in the heart. A vasovagal
response may occur, causing bradycardia. The
nurse must preoxygenate the client before
suctioning and limit the suctioning pass to 10
seconds.
18.Answer C. During suctioning, the nurse
should monitor the client closely for side
effects, including hypoxemia, cardiac
irregularities such as a decrease in heart rate
resulting from vagal stimulation, mucosal
trauma, hypotension, and paroxysmal
coughing. If side effects develop, especially
cardiac irregularities, the procedure is stopped
and the client is reoxygenated.
19.Answer A. In an acidotic condition, the pH
would be low, indicating the acidosis. In
addition, a low bicarbonate level along with
the low pH would indicate a metabolic state.
Therefore, options B, C, and D are incorrect.
20.Answer A. The common clinical
manifestations of pulmonary embolism are
tachypnea, tachycardia, dyspnea, and chest
pain.
21.Answer A. The client should be instructed to
hold his or her breath for at least 10 to 15
seconds before exhaling the mist. Options B,
C, and D are accurate instructions regarding
the use of the inhaler.
22.Answer D. After bronchoscopy, the nurse
keeps the client on NPO status until the gag
reflex returns because the preoperative
sedation and local anesthesia impair
swallowing and the protective laryngeal
reflexes for a number of hours. Additional
fluids are unnecessary because no contrast dye
is used that would need flushing from the
system. Atropine and midazolam would be
administered before the procedure, not after.
23.Answer D. Rib fractures are a common
injury, especially in the older client, and result
from a blunt injury or a fall. Typical signs and
symptoms include pain and tenderness
localized at the fracture site and exacerbated
by inspiration and palpation, shallow
respirations, splinting or guarding the chest
protectively to minimize chest movement, and
possible bruising at the fracture site.
Paradoxical respirations are seen with flail
chest.
24.Answer C. Flail chest results from fracture of
two or more ribs in at least two places each.
This results in a “floating” section of ribs.
Because this section is unattached to the rest
of the bony rib cage, this segment results in
paradoxical chest movement. This means that
the force of inspiration pulls the fractured
segment inward, while the rest of the chest
expands. Similarly, during exhalation, the
segment balloons outward while the rest of
 the chest moves inward. This is a telltale sign
of flail chest.
25.Answer A. Pneumothorax is characterized by
restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion,
and diminished or absent breath sounds on the
affected side. Pneumothorax can cause
increased airway pressure because of
resistance to lung inflation. Acute respiratory
distress syndrome and pulmonary embolism
are not characterized by absent breath sounds.
An endotracheal tube that is inserted too far
can cause absent breath sounds, but the lack
of breath sounds most likely would be on the
left side because of the degree of curvature of
the right and left main stem bronchi.
26.Answer C. Instructions for using a metered-
dose inhaler include shaking the canister,
holding it right side up, inhaling slowly and
evenly through the mouth, delivering one
spray per breath, and holding the breath after
inhalation.
27.Answer D. The earliest detectable sign of
acute respiratory distress syndrome is an
increased respiratory rate, which can begin
from 1 to 96 hours after the initial insult to the
body. This is followed by increasing dyspnea,
air hunger, retraction of accessory muscles,
and cyanosis. Breath sounds may be clear or
consist of fine inspiratory crackles or diffuse
coarse crackles.
28.Answer C. The normal pulmonary capillary
wedge pressure (PCWP) is 8 to 13 mm Hg,
and the client is considered to have high
readings if they exceed 18 to 20 mm Hg. The
client with acute respiratory distress syndrome
has a normal PCWP, which is an expected
finding because the edema is in the
interstitium of the lung and is noncardiac.
29.Answer A. The client with emphysema has
hyperinflation of the alveoli and flattening of
the diaphragm. These lead to increased
anteroposterior diameter, referred to as “barrel
chest.” The client also has dyspnea with
prolonged expiration and has hyperresonant
lungs to percussion.
30.Answer B. The client with tuberculosis
usually experiences cough (productive or
nonproductive), fatigue, anorexia, weight loss,
dyspnea, hemoptysis, chest discomfort or
pain, chills and sweats (which may occur at
night), and a low-grade fever.
 NCLEX Practice Exam for Respiratory System 3
1.    A nurse is preparing to obtain a
sputum specimen from a male client.
Which of the following nursing actions will
facilitate obtaining the specimen?
A. Limiting fluid
B. Having the client take deep breaths
C. Asking the client to spit into the collection
container
D. Asking the client to obtain the specimen after
eating
2.    Nurse Joy is caring for a client after a
bronchoscopy and biopsy. Which of the
following signs, if noticed in the client,
should be reported immediately to the
physician?
A. Dry cough
B. Hermaturia
C. Bronchospasm
D. Blood-streaked sputum
3.    A nurse is suctioning fluids from a
male client via a tracheostomy tube.
When suctioning, the nurse must limit the
suctioning time to a maximum of:
A. 1 minute
B. 5 seconds
C. 10 seconds
D. 30 seconds
4.    A nurse is suctioning fluids from a
female client through an endotracheal
tube. During the suctioning procedure, the
nurse notes on the monitor that the heart
rate is decreasing. Which if the following
is the appropriate nursing intervention?
A. Continue to suction
B. Notify the physician immediately
C. Stop the procedure and reoxygenate the client
D. Ensure that the suction is limited to 15
seconds
5.    A male adult client is suspected of
having a pulmonary embolus. A nurse
assesses the client, knowing that which of
the following is a common clinical
manifestation of pulmonary embolism?
A. Dyspnea
B. Bradypnea
C. Bradycardia
D. Decreased respirations
6.    A slightly obese female client with a
history of allergy-induced asthma,
hypertension, and mitral valve prolapse is
admitted to an acute care facility for
elective surgery. The nurse obtains a
complete history and performs a thorough
physical examination, paying special
attention to the cardiovascular and
respiratory systems. When percussing the
client’s chest wall, the nurse expects to
elicit:
A. Resonant sounds.
B. Hyperresonant sounds.
C. Dull sounds.
D. Flat sounds.
7.    A male client who weighs 175 lb
(79.4 kg) is receiving aminophylline
(Aminophyllin) (400 mg in 500 ml) at 50
ml/hour. The theophylline level is reported
as 6 mcg/ml. The nurse calls the
physician who instructs the nurse to
change the dosage to 0.45 mg/kg/hour.
The nurse should:
A. Question the order because it’s too low.
B. Question the order because it’s too high.
C. Set the pump at 45 ml/hour.
D. Stop the infusion and have the laboratory
repeat the theophylline measurement.
8.    The nurse is teaching a male client
with chronic bronchitis about breathing
exercises. Which of the following should
the nurse include in the teaching?
A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathing.
9.    Which phrase is used to describe the
volume of air inspired and expired with a
normal breath?
A. Total lung capacity
B. Forced vital capacity
C. Tidal volume
D. Residual volume
10.    A male client abruptly sits up in bed,
reports having difficulty breathing and has
an arterial oxygen saturation of 88%.
 Which mode of oxygen delivery would
most likely reverse the manifestations?
A. Simple mask
B. Non-rebreather mask
C. Face tent
D. Nasal cannula
11.    A female client must take
streptomycin for tuberculosis. Before
therapy begins, the nurse should instruct
the client to notify the physician if which
health concern occurs?
A. Impaired color discrimination
B. Increased urinary frequency
C. Decreased hearing acuity
D. Increased appetite
12.    A male client is asking the nurse a
question regarding the Mantoux test for
tuberculosis. The nurse should base her
response on the fact that the:
A. Area of redness is measured in 3 days and
determines whether tuberculosis is present.
B. Skin test doesn’t differentiate between active
and dormant tuberculosis infection.
C. Presence of a wheal at the injection site in 2
days indicates active tuberculosis.
D. Test stimulates a reddened response in some
clients and requires a second test in 3 months.
13.    A female adult client has a
tracheostomy but doesn’t require
continuous mechanical ventilation. When
weaning the client from the tracheostomy
tube, the nurse initially should plug the
opening in the tube for:
A. 15 to 60 seconds.
B. 5 to 20 minutes.
C. 30 to 40 minutes.
D. 45 to 60 minutes.
14.    Nurse Oliver observes constant
bubbling in the water-seal chamber of a
closed chest drainage system. What
should the nurse conclude?
A. The system is functioning normally
B. The client has a pneumothorax.
C. The system has an air leak.
D. The chest tube is obstructed.
15.    A black client with asthma seeks
emergency care for acute respiratory
distress. Because of this client’s dark
skin, the nurse should assess for
cyanosis by inspecting the:
A. Lips.
B. Mucous membranes.
C. Nail beds.
D. Earlobes.
16.    For a male client with an
endotracheal (ET) tube, which nursing
action is most essential?
A. Auscultating the lungs for bilateral breath
sounds
B. Turning the client from side to side every 2
hours
C. Monitoring serial blood gas values every 4
hours
D. Providing frequent oral hygiene
17.    The nurse assesses a male client’s
respiratory status. Which observation
indicates that the client is experiencing
difficulty breathing?
A. Diaphragmatic breathing
B. Use of accessory muscles
C. Pursed-lip breathing
D. Controlled breathing
18.    A female client is undergoing a
complete physical examination as a
requirement for college. When checking
the client’s respiratory status, the nurse
observes respiratory excursion to help
assess:
A. Lung vibrations.
B. Vocal sounds.
C. Breath sounds.
D. Chest movements.
19.    A male client comes to the
emergency department complaining of
sudden onset of diarrhea, anorexia,
malaise, cough, headache, and recurrent
chills. Based on the client’s history and
physical findings, the physician suspects
legionnaires’ disease. While awaiting
diagnostic test results, the client is
admitted to the facility and started on
antibiotic therapy. What is the drug of
choice for treating legionnaires’ disease?
A. Erythromycin (Erythrocin)
B. Rifampin (Rifadin)
C. Amantadine (Symmetrel)
D. Amphotericin B (Fungizone)
20.    A male client with chronic
obstructive pulmonary disease (COPD) is
recovering from a myocardial infarction.
Because the client is extremely weak and
can’t produce an effective cough, the
nurse should monitor closely for:
A. Pleural effusion.
B. Pulmonary edema.
C. Atelectasis.
D. Oxygen toxicity.
21.    The nurse in charge is teaching a
client with emphysema how to perform
pursed-lip breathing. The client asks the
nurse to explain the purpose of this
breathing technique. Which explanation
should the nurse provide?
A. It helps prevent early airway collapse.
B. It increases inspiratory muscle strength.
C. It decreases use of accessory breathing
muscles.
D. It prolongs the inspiratory phase of
respiration.
22.    After receiving an oral dose of
codeine for an intractable cough, the male
client asks the nurse, “How long will it
take for this drug to work?” How should
the nurse respond?
A. In 30 minutes
B. In 1 hour
C. In 2.5 hours
D. In 4 hours
23.    A male client suffers adult
respiratory distress syndrome as a
consequence of shock. The client’s
condition deteriorates rapidly, and
endotracheal (ET) intubation and
mechanical ventilation are initiated. When
the high-pressure alarm on the
mechanical ventilator sounds, the nurse
starts to check for the cause. Which
condition triggers the high-pressure
alarm?
A. Kinking of the ventilator tubing
B. A disconnected ventilator tube
C. An ET cuff leak
D. A change in the oxygen concentration without
resetting the oxygen level alarm
24.    A female client with chronic
obstructive pulmonary disease (COPD)
takes anhydrous theophylline, 200 mg
P.O. every 8 hours. During a routine clinic
visit, the client asks the nurse how the
drug works. What is the mechanism of
action of anhydrous theophylline in
treating a nonreversible obstructive
airway disease such as COPD?
A. It makes the central respiratory center more
sensitive to carbon dioxide and stimulates the
respiratory drive.
B. It inhibits the enzyme phosphodiesterase,
decreasing degradation of cyclic adenosine
monophosphate, a bronchodilator.
C. It stimulates adenosine receptors, causing
bronchodilation.
D. It alters diaphragm movement, increasing
chest expansion and enhancing the lung’s
capacity for gas exchange.
25.    A male client with pneumococcal
pneumonia is admitted to an acute care
facility. The client in the next room is
being treated for mycoplasmal
pneumonia. Despite the different causes
of the various types of pneumonia, all of
them share which feature?
A. Inflamed lung tissue
B. Sudden onset
C. Responsiveness to penicillin.
D. Elevated white blood cell (WBC) count
26.    A client with Guillain-Barré
syndrome develops respiratory acidosis
as a result of reduced alveolar ventilation.
Which combination of arterial blood gas
(ABG) values confirms respiratory
acidosis?
A. pH, 5.0; PaCO2 30 mm Hg
B. pH, 7.40; PaCO2 35 mm Hg
C. pH, 7.35; PaCO2 40 mm Hg
D. pH, 7.25; PaCO2 50 mm Hg
27.    A male client admitted to an acute
care facility with pneumonia is receiving
supplemental oxygen, 2 L/minute via
nasal cannula. The client’s history
includes chronic obstructive pulmonary
 disease (COPD) and coronary artery
disease. Because of these history
findings, the nurse closely monitors the
oxygen flow and the client’s respiratory
status. Which complication may arise if
the client receives a high oxygen
concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
28.    At 11 p.m., a male client is admitted
to the emergency department. He has a
respiratory rate of 44 breaths/minute.
He’s anxious, and wheezes are audible.
The client is immediately given oxygen by
face mask and methylprednisolone
(Depo-medrol) I.V. At 11:30 p.m., the
client’s arterial blood oxygen saturation is
86% and he’s still wheezing. The nurse
should plan to administer:
A. Alprazolam (Xanax).
B. Propranolol (Inderal)
C. Morphine.
D. Albuterol (Proventil).
29.    After undergoing a thoracotomy, a
male client is receiving epidural
analgesia. Which assessment finding
indicates that the client has developed the
most serious complication of epidural
analgesia?
A. Heightened alertness
B. Increased heart rate
C. Numbness and tingling of the extremities
D. Respiratory depression
30.    The nurse in charge  formulates a
nursing diagnosis of Activity intolerance
related to inadequate oxygenation and
dyspnea for a client with chronic
bronchitis. To minimize this problem, the
nurse instructs the client to avoid
conditions that increase oxygen
demands. Such conditions include:
A. Drinking more than 1,500 ml of fluid daily.
B. Being overweight.
C. Eating a high-protein snack at bedtime.
D. Eating more than three large meals a day.
Answers and Rationales
1. Answer B. To obtain a sputum specimen, the
client should rinse the mouth to reduce
contamination, breathe deeply, and then
cough into a sputum specimen container. The
client should be encouraged to cough and not
spit so as to obtain sputum. Sputum can be
thinned by fluids or by a respiratory treatment
such as inhalation of nebulized saline or
water. The optimal time to obtain a specimen
is on arising in the morning.
2. Answer D. If a biopsy was performed during
a bronchoscopy, blood-streaked sputum is
expected for several hours. Frank blood
indicates hemorrhage. A dry cough may be
expected. The client should be assessed for
signs of complications, which would include
cyanosis, dyspnea, stridor, bronchospasm,
hemoptysis, hypotension, tachycardia, and
dysrhythmias. Hematuria is unrelated to this
procedure.
3. Answer C. Hypoxemia can be caused by
prolonged suctioning, which stimulates the
pacemaker cells in the heart. A vasovagal
response may occur, causing bradycardia. The
nurse must preoxygenate the client before
suctioning and limit the suctioning pass to 10
seconds.
4. Answer C. During suctioning, the nurse
should monitor the client closely for side
effects, including hypoxemia, cardiac
irregularities such as a decrease in heart rate
resulting from vagal stimulation, mucosal
trauma, hypotension, and paroxysmal
coughing. If side effects develop, especially
cardiac irregularities, the procedure is stopped
and the client is reoxygenated.
5. Answer A. The common clinical
manifestations of pulmonary embolism are
tachypnea, tachycardia, dyspnea, and chest
pain.
6. Answer A. When percussing the chest wall,
the nurse expects to elicit resonant sounds —
low-pitched, hollow sounds heard over normal
lung tissue. Hyperresonant sounds indicate
increased air in the lungs or pleural space;
they’re louder and lower pitched than resonant
sounds. Although hyperresonant sounds occur
in such disorders as emphysema and
pneumothorax, they may be normal in
children and very thin adults. Dull sounds,
normally heard only over the liver and heart,
may occur over dense lung tissue, such as
from consolidation or a tumor. Dull sounds
are thudlike and of medium pitch. Flat sounds,
 soft and high-pitched, are heard over airless
tissue and can be replicated by percussing the
thigh or a bony structure.
7. Answer A. A therapeutic theophylline level is
10 to 20 mcg/ml. The client is currently
receiving 0.5 mg/kg/hour of aminophylline.
Because the client’s theophylline level is sub-
therapeutic, reducing the dose (which is what
the physician’s order would do) would be
inappropriate. Therefore, the nurse should
question the order.
8. Answer C. In chronic bronchitis the
diaphragm is flat and weak. Diaphragmatic
breathing helps to strengthen the diaphragm
and maximizes ventilation. Exhalation should
be longer than inhalation to prevent collapse
of the bronchioles. The client with chronic
bronchitis should exhale through pursed lips
to prolong exhalation, keep the bronchioles
from collapsing, and prevent air trapping.
Diaphragmatic breathing — not chest
breathing — increases lung expansion.
9. Answer C. Tidal volume refers to the volume
of air inspired and expired with a normal
breath. Total lung capacity is the maximal
amount of air the lungs and respiratory
passages can hold after a forced inspiration.
Forced vital capacity is the vital capacity
performed with a maximally forced
expiration. Residual volume is the maximal
amount of air left in the lung after a maximal
expiration.
10.Answer B. A non-rebreather mask can deliver
levels of the fraction of inspired oxygen
(FIO ) as high as 100%. Other modes —
2 cyanosis because they’re affected by skin
simple mask, face tent, and nasal cannula —
deliver lower levels of FIO .
2 16.Answer A. For a client with an ET tube, the
11.Answer C. Decreased hearing acuity indicates
ototoxicity, a serious adverse effect of
streptomycin therapy. The client should notify
the physician immediately if it occurs so that
streptomycin can be discontinued and an
alternative drug can be prescribed. The other
options aren’t associated with streptomycin.
Impaired color discrimination indicates color
blindness; increased urinary frequency and
increased appetite accompany diabetes
mellitus.
12.Answer B. The Mantoux test doesn’t
differentiate between active and dormant
infections. If a positive reaction occurs, a
sputum smear and culture as well as a chest
X-ray are necessary to provide more
information. Although the area of redness is
measured in 3 days, a second test may be
needed; neither test indicates that tuberculosis
is active. In the Mantoux test, an induration 5
to 9 mm in diameter indicates a borderline
reaction; a larger induration indicates a
positive reaction. The presence of a wheal
within 2 days doesn’t indicate active
tuberculosis.
13.Answer B. Initially, the nurse should plug the
opening in the tracheostomy tube for 5 to 20
minutes, then gradually lengthen this interval
according to the client’s respiratory status. A
client who doesn’t require continuous
mechanical ventilation already is breathing
without assistance, at least for short periods;
therefore, plugging the opening of the tube for
only 15 to 60 seconds wouldn’t be long
enough to reveal the client’s true tolerance to
the procedure. Plugging the opening for more
than 20 minutes would increase the risk of
acute respiratory distress because the client
requires an adjustment period to start
breathing normally.
14.Answer C. Constant bubbling in the chamber
indicates an air leak and requires immediate
intervention. The client with a pneumothorax
will have intermittent bubbling in the water-
seal chamber. Clients without a pneumothorax
should have no evidence of bubbling in the
chamber. If the tube is obstructed, the nurse
should notice that the fluid has stopped
fluctuating in the water-seal chamber.
15.Answer B. Skin color doesn’t affect the
mucous membranes. The lips, nail beds, and
earlobes are less reliable indicators of
color.
most important nursing action is auscultating
the lungs regularly for bilateral breath sounds
to ensure proper tube placement and effective
oxygen delivery. Although the other options
are appropriate for this client, they’re
secondary to ensuring adequate oxygenation.
17.Answer B.  The use of accessory muscles for
respiration indicates the client is having
difficulty breathing. Diaphragmatic and
pursed-lip breathing are two controlled
breathing techniques that help the client
conserve energy.
18.Answer D. The nurse observes respiratory
excursion to help assess chest movements.
Normally, thoracic expansion is symmetrical;
unequal expansion may indicate pleural
effusion, atelectasis, pulmonary embolus, or a
rib or sternum fracture. The nurse assesses
 vocal sounds to evaluate air flow when
checking for tactile fremitus; after asking the
client to say “99,” the nurse palpates the
vibrations transmitted from the
bronchopulmonary system along the solid
surfaces of the chest wall to the nurse’s palms.
The nurse assesses breath sounds during
auscultation.
19.Answer A. Erythromycin is the drug of
choice for treating legionnaires’ disease.
Rifampin may be added to the regimen if
erythromycin alone is ineffective; however, it
isn’t administered first. Amantadine, an
antiviral agent, and amphotericin B, an
antifungal agent, are ineffective against
legionnaires’ disease, which is caused by
bacterial infection.
20.Answer C. In a client with COPD, an
ineffective cough impedes secretion removal.
This, in turn, causes mucus plugging, which
leads to localized airway obstruction — a
known cause of atelectasis. An ineffective
cough doesn’t cause pleural effusion (fluid
accumulation in the pleural space). Pulmonary
edema usually results from left-sided heart
failure, not an ineffective cough. Although
many noncardiac conditions may cause
pulmonary edema, an ineffective cough isn’t
one of them. Oxygen toxicity results from
prolonged administration of high oxygen
concentrations, not an ineffective cough.
21.Answer A. Pursed-lip breathing helps prevent
early airway collapse. Learning this technique
helps the client control respiration during
periods of excitement, anxiety, exercise, and
respiratory distress. To increase inspiratory
muscle strength and endurance, the client may
need to learn inspiratory resistive breathing.
To decrease accessory muscle use and thus
reduce the work of breathing, the client may
need to learn diaphragmatic (abdominal)
breathing. In pursed-lip breathing, the client
mimics a normal inspiratory-expiratory (I:E)
ratio of 1:2. (A client with emphysema may
have an I:E ratio as high as 1:4.)
22.Answer A. Codeine’s onset of action is 30
minutes. Its peak concentration occurs in
about 1 hour; its half-life, in 2.5 hours; and its
duration of action is 4 to 6 hours.
23.Answer A. Conditions that trigger the high-
pressure alarm include kinking of the
ventilator tubing, bronchospasm or pulmonary
embolus, mucus plugging, water in the tube,
coughing or biting on the ET tube, and the
client’s being out of breathing rhythm with
the ventilator. A disconnected ventilator tube
or an ET cuff leak would trigger the low-
pressure alarm. Changing the oxygen
concentration without resetting the oxygen
level alarm would trigger the oxygen alarm.
24.Answer A.  Anhydrous theophylline and
other methylxanthine agents make the central
respiratory center more sensitive to CO  and
2
stimulate the respiratory drive. Inhibition of
phosphodiesterase is the drug’s mechanism of
action in treating asthma and other reversible
obstructive airway diseases — not COPD.
Methylxanthine agents inhibit rather than
stimulate adenosine receptors. Although these
agents reduce diaphragmatic fatigue in clients
with chronic bronchitis or emphysema, they
don’t alter diaphragm movement to increase
chest expansion and enhance gas exchange.
25.Answer A. The common feature of all types
of pneumonia is an inflammatory pulmonary
response to the offending organism or agent.
Although most types of pneumonia have a
sudden onset, a few (such as anaerobic
bacterial pneumonia and mycoplasmal
pneumonia) have an insidious onset.
Antibiotic therapy is the primary treatment for
most types of pneumonia; however, the
antibiotic must be specific for the causative
agent, which may not be responsive to
penicillin. A few types of pneumonia, such as
viral pneumonia, aren’t treated with
antibiotics. Although pneumonia usually
causes an elevated WBC count, some types,
such as mycoplasmal pneumonia, don’t.
26.Answer D. In respiratory acidosis, ABG
analysis reveals an arterial pH below 7.35 and
partial pressure of arterial carbon dioxide
(PaCO ) above 45 mm Hg. Therefore, the
2
combination of a pH value of 7.25 and a
PaCO  value of 50 mm Hg confirms
2
respiratory acidosis. A pH value of 5.0 with a
PaCO value of 30 mm Hg indicates
2
respiratory alkalosis. Options B and C
represent normal ABG values, reflecting
normal gas exchange in the lungs.
27.Answer A. Hypoxia is the main breathing
stimulus for a client with COPD. Excessive
oxygen administration may lead to apnea by
removing that stimulus. Anginal pain results
from a reduced myocardial oxygen supply. A
client with COPD may have anginal pain from
generalized vasoconstriction secondary to
hypoxia; however, administering oxygen at
any concentration dilates blood vessels, easing
anginal pain. Respiratory alkalosis results
 from alveolar hyperventilation, not excessive
oxygen administration. In a client with COPD,
high oxygen concentrations decrease the
ventilatory drive, leading to respiratory
acidosis, not alkalosis. High oxygen
concentrations don’t cause metabolic acidosis.
28.Answer D. The client is hypoxemic because
of bronchoconstriction as evidenced by
wheezes and a subnormal arterial oxygen
saturation level. The client’s greatest need is
bronchodilation, which can be accomplished
by administering bronchodilators. Albuterol is
a beta  adrenergic agonist, which causes
2

dilation of the bronchioles. It’s given by

nebulization or metered-dose inhalation and
may be given as often as every 30 to 60
minutes until relief is accomplished.
Alprazolam is an anxiolytic and central
nervous system depressant, which could
suppress the client’s breathing. Propranolol is
contraindicated in a client who’s wheezing
because it’s a beta  adrenergic antagonist.
2

Morphine is a respiratory center depressant

and is contraindicated in this situation.
29.Answer D. Respiratory depression is the most
serious complication of epidural analgesia.
Other potential complications include
hypotension, decreased sensation and
movement of the extremities, allergic
reactions, and urine retention. Typically,
epidural analgesia causes central nervous
system depression (indicated by drowsiness)
as well as a decreased heart rate and blood
pressure.
30.Answer B. Conditions that increase oxygen
demands include obesity, smoking, exposure
to temperature extremes, and stress. A client
with chronic bronchitis should drink at least
2,000 ml of fluid daily to thin mucus
secretions; restricting fluid intake may be
harmful. The nurse should encourage the
client to eat a high-protein snack at bedtime
because protein digestion produces an amino
acid with sedating effects that may ease the
insomnia associated with chronic bronchitis.
Eating more than three large meals a day may
cause fullness, making breathing
uncomfortable and difficult; however, it
doesn’t increase oxygen demands. To help
maintain adequate nutritional intake, the client
with chronic bronchitis should eat small,
frequent meals (up to six a day).
 NCLEX Practice Exam for Neurologic System 1
1. If a male client experienced a
cerebrovascular accident (CVA) that
damaged the hypothalamus, the nurse
would anticipate that the client has
problems with:
A. body temperature control.
B. balance and equilibrium.
C. visual acuity.
D. thinking and reasoning.
2. A female client admitted to an acute
care facility after a car accident develops
signs and symptoms of increased
intracranial pressure (ICP). The client is
intubated and placed on mechanical
ventilation to help reduce ICP. To prevent
a further rise in ICP caused by suctioning,
the nurse anticipates administering which
drug endotracheally before suctioning?
A. phenytoin (Dilantin)
B. mannitol (Osmitrol)
C. lidocaine (Xylocaine)
D. furosemide (Lasix)
3. After striking his head on a tree while
falling from a ladder, a young man age 18
is admitted to the emergency department.
He’s unconscious and his pupils are
nonreactive. Which intervention would be
the most dangerous for the client?
A. Give him a barbiturate.
B. Place him on mechanical ventilation.
C. Perform a lumbar puncture.
D. Elevate the head of his bed.
4. When obtaining the health history from
a male client with retinal detachment, the
nurse expects the client to report:
A. light flashes and floaters in front of the eye.
B. a recent driving accident while changing
lanes.
C. headaches, nausea, and redness of the eyes.
D. frequent episodes of double vision.
5. Which nursing diagnosis takes highest
priority for a client with Parkinson’s crisis?
A. Imbalanced nutrition: Less than body
requirements
B. Ineffective airway clearance
C. Impaired urinary elimination
D. Risk for injury
6. To encourage adequate nutritional
intake for a female client with Alzheimer’s
disease, the nurse should:
A. stay with the client and encourage him to eat.
B. help the client fill out his menu.
C. give the client privacy during meals.
D. fill out the menu for the client.
7. The nurse is performing a mental
status examination on a male client
diagnosed with subdural hematoma. This
test assesses which of the following?
A. Cerebellar function
B. Intellectual function
C. Cerebral function
D. Sensory function
8. Shortly after admission to an acute
care facility, a male client with a seizure
disorder develops status epilepticus. The
physician orders diazepam (Valium) 10
mg I.V. stat. How soon can the nurse
administer a second dose of diazepam, if
needed and prescribed?
A. In 30 to 45 seconds
B. In 10 to 15 minutes
C. In 30 to 45 minutes
D. In 1 to 2 hours
9. A female client complains of periorbital
aching, tearing, blurred vision, and
photophobia in her right eye.
Ophthalmologic examination reveals a
small, irregular, nonreactive pupil — a
condition resulting from acute iris
inflammation (iritis). As part of the client’s
therapeutic regimen, the physician
prescribes atropine sulfate (Atropisol),
two drops of 0.5% solution in the right eye
twice daily. Atropine sulfate belongs to
which drug classification?
A. Parasympathomimetic agent
B. Sympatholytic agent
C. Adrenergic blocker
D. Cholinergic blocker
10. Emergency medical technicians
transport a 27-year-old iron worker to the
emergency department. They tell the
nurse, “He fell from a two-story building.
 He has a large contusion on his left chest
and a hematoma in the left parietal area.
He has a compound fracture of his left
femur and he’s comatose. We intubated
him and he’s maintaining an arterial
oxygen saturation of 92% by pulse
oximeter with a manual-resuscitation
bag.” Which intervention by the nurse has
the highest priority?
A. Assessing the left leg
B. Assessing the pupils
C. Placing the client in Trendelenburg’s position
D. Assessing level of consciousness
11. An auto mechanic accidentally has
battery acid splashed in his eyes. His
coworkers irrigate his eyes with water for
20 minutes, and then take him to the
emergency department of a nearby
hospital, where he receives emergency
care for corneal injury. The physician
prescribes dexamethasone (Maxidex
Ophthalmic Suspension), two drops of
0.1% solution to be instilled initially into
the conjunctival sacs of both eyes every
hour; and polymyxin B sulfate (Neosporin
Ophthalmic), 0.5% ointment to be placed
in the conjunctival sacs of both eyes
every 3 hours. Dexamethasone exerts its
therapeutic effect by:
A. increasing the exudative reaction of ocular
tissue.
B. decreasing leukocyte infiltration at the site of
ocular inflammation.
C. inhibiting the action of carbonic anhydrase.
D. producing a miotic reaction by stimulating
and contracting the sphincter muscles of the
iris.
12. Nurse April is caring for a client who
underwent a lumbar laminectomy 2 days
ago. Which of the following findings
should the nurse consider abnormal?
A. More back pain than the first postoperative
day
B. Paresthesia in the dermatomes near the
wounds
C. Urine retention or incontinence
D. Temperature of 99.2° F (37.3° C)
13. After an eye examination, a male
client is diagnosed with open-angle
glaucoma. The physician prescribes
pilocarpine ophthalmic solution (Pilocar),
0.25% gtt i, OU q.i.d. Based on this
prescription, the nurse should teach the
client or a family member to administer
the drug by:
A. instilling one drop of pilocarpine 0.25% into
both eyes daily.
B. instilling one drop of pilocarpine 0.25% into
both eyes four times daily.
C. instilling one drop of pilocarpine 0.25% into
the right eye daily.
D. instilling one drop of pilocarpine 0.25% into
the left eye four times daily.
14. A female client who’s paralyzed on
the left side has been receiving physical
therapy and attending teaching sessions
about safety. Which behavior indicates
that the client accurately understands
safety measures related to paralysis?
A. The client leaves the side rails down.
B. The client uses a mirror to inspect the skin.
C. The client repositions only after being
reminded to do so.
D. The client hangs the left arm over the side of
the wheelchair.
15. A male client in the emergency
department has a suspected neurologic
disorder. To assess gait, the nurse asks
the client to take a few steps; with each
step, the client’s feet make a half circle.
To document the client’s gait, the nurse
should use which term?
A. Ataxic
B. Dystrophic
C. Helicopod
D. Steppage
16. A client, age 22, is admitted with
bacterial meningitis. Which hospital room
would be the best choice for this client?
A. A private room down the hall from the nurses’
station
B. An isolation room three doors from the
nurses’ station
C. A semiprivate room with a 32-year-old client
who has viral meningitis
D. A two-bed room with a client who previously
had bacterial meningitis
17. A physician diagnoses a client with
myasthenia gravis, prescribing
pyridostigmine (Mestinon), 60 mg P.O.
every 3 hours. Before administering this
anticholinesterase agent, the nurse
reviews the client’s history. Which
preexisting condition would contraindicate
the use of pyridostigmine?
A. Ulcerative colitis
B. Blood dyscrasia
C. Intestinal obstruction
D. Spinal cord injury
18. A female client is admitted to the
facility for investigation of balance and
coordination problems, including possible
Ménière’s disease. When assessing this
client, the nurse expects to note:
A. vertigo, tinnitus, and hearing loss.
B. vertigo, vomiting, and nystagmus
C. vertigo, pain, and hearing impairment.
D. vertigo, blurred vision, and fever.
19. A male client with a conductive
hearing disorder caused by ankylosis of
the stapes in the oval window undergoes
a stapedectomy to remove the stapes and
replace the impaired bone with a
prosthesis. After the stapedectomy, the
nurse should provide which client
instruction?
A. “Lie in bed with your head elevated, and
refrain from blowing your nose for 24 hours.”
B. “Try to ambulate independently after about 24
hours.”
C. “Shampoo your hair every day for 10 days to
help prevent ear infection.”
D. “Don’t fly in an airplane, climb to high
altitudes, make sudden movements, or expose
yourself to loud sounds for 30 days.”
20. Nurse Oliver is monitoring a client for
adverse reactions to dantrolene
(Dantrium). Which adverse reaction is
most common?
A. Excessive tearing
B. Urine retention
C. Muscle weakness
D. Slurred speech
21. The nurse is monitoring a male client
for adverse reactions to atropine sulfate
(Atropine Care) eyedrops. Systemic
absorption of atropine sulfate through the
conjunctiva can cause which adverse
reaction?
A. Tachycardia
B. Increased salivation
C. Hypotension
D. Apnea
22. A male client is admitted with a
cervical spine injury sustained during a
diving accident. When planning this
client’s care, the nurse should assign
highest priority to which nursing
diagnosis?
A. Impaired physical mobility
B. Ineffective breathing pattern
C. Disturbed sensory perception (tactile)
D. Self-care deficient: Dressing/grooming
23. A male client has a history of painful,
continuous muscle spasms. He has taken
several skeletal muscle relaxants without
experiencing relief. His physician
prescribes diazepam (Valium), 2 mg P.O.
twice daily. In addition to being used to
relieve painful muscle spasms, diazepam
also is recommended for:
A. long-term treatment of epilepsy.
B. postoperative pain management of
laminectomy clients.
C. postoperative pain management of diskectomy
clients
D. treatment of spasticity associated with spinal
cord lesions.
24. A female client who was found
unconscious at home is brought to the
hospital by a rescue squad. In the
intensive care unit, the nurse checks the
client’s oculocephalic (doll’s eye)
response by:
A.  introducing ice water into the external
auditory canal.
B. touching the cornea with a wisp of cotton.
C. turning the client’s head suddenly while
holding the eyelids open.
D. shining a bright light into the pupil.
 25. While reviewing a client’s chart, the
nurse notices that the female client has
myasthenia gravis. Which of the following
statements about neuromuscular blocking
agents is true for a client with this
condition?
A. The client may be less sensitive to the effects
of a neuromuscular blocking agent.
B. Succinylcholine shouldn’t be used;
pancuronium may be used in a lower dosage.
C. Pancuronium shouldn’t be used;
succinylcholine may be used in a lower
dosage.
D. Pancuronium and succinylcholine both require
cautious administration.
26. A male client is color blind. The nurse
understands that this client has a problem
with:
A. rods.
B. cones.
C. lens.
D. aqueous humor.
27. A female client who was trapped
inside a car for hours after a head-on
collision is rushed to the emergency
department with multiple injuries. During
the neurologic examination, the client
responds to painful stimuli with
decerebrate posturing. This finding
indicates damage to which part of the
brain?
A. Diencephalon
B. Medulla
C. Midbrain
D. Cortex
28. The nurse is assessing a 37-year-old
client diagnosed with multiple sclerosis.
Which of the following symptoms would
the nurse expect to find?
A. Vision changes
B. Absent deep tendon reflexes
C. Tremors at rest
D. Flaccid muscles
29. The nurse is caring for a male client
diagnosed with a cerebral aneurysm who
reports a severe headache. Which action
should the nurse perform?
A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the physician immediately.
30. During recovery from a
cerebrovascular accident (CVA), a female
client is given nothing by mouth, to help
prevent aspiration. To determine when
the client is ready for a liquid diet, the
nurse assesses the client’s swallowing
ability once each shift. This assessment
evaluates:
A. cranial nerves I and II.
B. cranial nerves III and V.
C. cranial nerves VI and VIII.
D. cranial nerves IX and X.
Answers and Rationales
1. Answer A. The body’s thermostat is located
in the hypothalamus; therefore, injury to that
area can cause problems of body temperature
control. Balance and equilibrium problems are
related to cerebellar damage. Visual acuity
problems would occur following occipital or
optic nerve injury. Thinking and reasoning
problems are the result of injury to the
cerebrum.
2. Answer C. Administering lidocaine via an
endotracheal tube may minimize elevations in
ICP caused by suctioning. Although mannitol
and furosemide may be given to reduce ICP,
they’re administered parenterally, not
endotracheally. Phenytoin doesn’t reduce ICP
directly but may be used to abolish seizures,
which can increase ICP. However, phenytoin
isn’t administered endotracheally.
3. Answer C. The client’s history and
assessment suggest that he may have
increased intracranial pressure (ICP). If this is
the case, lumbar puncture shouldn’t be done
because it can quickly decompress the central
nervous system and, thereby, cause additional
damage. After a head injury, barbiturates may
be given to prevent seizures; mechanical
ventilation may be required if breathing
deteriorates; and elevating the head of the bed
may be used to reduce ICP.
4. Answer A. The sudden appearance of light
flashes and floaters in front of the affected eye
is characteristic of retinal detachment.
Difficulty seeing cars in another driving lane
suggests gradual loss of peripheral vision,
which may indicate glaucoma. Headache,
nausea, and redness of the eyes are signs of
 acute (angle-closure) glaucoma. Double
vision is common in clients with cataracts.
5. Answer B. In Parkinson’s crisis, dopamine-
related symptoms are severely exacerbated,
virtually immobilizing the client. A client
confined to bed during such a crisis is at risk
for aspiration and pneumonia. Also, excessive
drooling increases the risk of airway
obstruction. Because of these concerns, the
nursing diagnosis of Ineffective airway
clearance takes highest priority. Although the
other options also are appropriate, they aren’t
immediately life-threatening.
6. Answer A. Staying with the client and
encouraging him to feed himself will ensure
adequate food intake. A client with
Alzheimer’s disease can forget how to eat.
Allowing privacy during meals, filling out the
menu, or helping the client to complete the
menu doesn’t ensure adequate nutritional
intake.
7. Answer C. The mental status examination
assesses functions governed by the cerebrum.
Some of these are orientation, attention span,
judgment, and abstract reasoning. Intellectual
functioning isn’t the only cerebral activity.
Cerebellar function testing assesses
coordination, equilibrium, and fine motor
movement. Sensory function testing involves
assessment of pain, light-touch sensation, and
temperature discrimination.
8. Answer B. When used to treat status
epilepticus, diazepam may be given every 10
to 15 minutes, as needed, to a maximum dose
of 30 mg. The nurse can repeat the regimen in
2 to 4 hours, if necessary, but the total dose
shouldn’t exceed 100 mg in 24 hours. The
nurse must not administer I.V. diazepam
faster than 5 mg/minute. Therefore, the dose
can’t be repeated in 30 to 45 seconds because
the first dose wouldn’t have been
administered completely by that time. Waiting
longer than 15 minutes to repeat the dose
would increase the client’s risk of
complications associated with status
epilepticus.
9. Answer D. Atropine sulfate is a cholinergic
blocker. It isn’t a parasympathomimetic agent,
a sympatholytic agent, or an adrenergic
blocker.
10.Answer A. In the scenario, airway and
breathing are established so the nurse’s next
priority should be circulation. With a
compound fracture of the femur, there is a
high risk of profuse bleeding; therefore, the
nurse should assess the site. Neurologic
assessment is a secondary concern to airway,
breathing, and circulation. The nurse doesn’t
have enough data to warrant putting the client
in Trendelenburg’s position.
11.Answer B. Dexamethasone exerts its
therapeutic effect by decreasing leukocyte
infiltration at the site of ocular inflammation.
This reduces the exudative reaction of
diseased tissue, lessening edema, redness, and
scarring. Dexamethasone and other anti-
inflammatory agents don’t inhibit the action
of carbonic anhydrase or produce any type of
miotic reaction.
12.Answer C. Urine retention or incontinence
may indicate cauda equina syndrome, which
requires immediate surgery. An increase in
pain on the second postoperative day is
common because the long-acting local
anesthetic, which may have been injected
during surgery, will wear off. While
paresthesia is common after surgery,
progressive weakness or paralysis may
indicate spinal nerve compression. A mild
fever is also common after surgery but is
considered significant only if it reaches 101°
F (38.3° C).
13.Answer B. The abbreviation “gtt” stands for
drop, “i” is the apothecary symbol for the
number 1, OU signifies both eyes, and “q.i.d.”
means four times a day. Therefore, one drop
of pilocarpine 0.25% should be instilled into
both eyes four times daily.
14.Answer B. Using a mirror enables the client
to inspect all areas of the skin for signs of
breakdown without the help of staff or family
members. The client should keep the side rails
up to help with repositioning and to prevent
falls. The paralyzed client should take
responsibility for repositioning or for
reminding the staff to assist with it, if needed.
A client with left-side paralysis may not
realize that the left arm is hanging over the
side of the wheelchair. However, the nurse
should call this to the client’s attention
because the arm can get caught in the wheel
spokes or develop impaired circulation from
being in a dependent position for too long.
15.Answer C. A helicopod gait is an abnormal
gait in which the client’s feet make a half
circle with each step. An ataxic gait is
staggering and unsteady. In a dystrophic gait,
the client waddles with the legs far apart. In a
steppage gait, the feet and toes raise high off
 the floor and the heel comes down heavily
with each step.
16.Answer B. A client with bacterial meningitis
should be kept in isolation for at least 24
hours after admission and, during the initial
acute phase, should be as close to the nurses’
station as possible to allow maximal
observation. Placing the client in a room with
a client who has viral meningitis may cause
harm to both clients because the organisms
causing viral and bacterial meningitis differ;
either client may contract the other’s disease.
Immunity to bacterial meningitis can’t be
acquired; therefore, a client who previously
had bacterial meningitis shouldn’t be put at
risk by rooming with a client who has just
been diagnosed with this disease.
17.Answer C. Anticholinesterase agents such as
pyridostigmine are contraindicated in a client
with a mechanical obstruction of the intestines
or urinary tract, peritonitis, or hypersensitivity
to anticholinesterase agents. Ulcerative colitis,
blood dyscrasia, and spinal cord injury don’t
contraindicate use of the drug.
18.Answer A. Ménière’s disease, an inner ear
disease, is characterized by the symptom triad
of vertigo, tinnitus, and hearing loss. The
combination of vertigo, vomiting, and
nystagmus suggests labyrinthitis. Ménière’s
disease rarely causes pain, blurred vision, or
fever.
19.Answer D. For 30 days after a stapedectomy,
the client should avoid air travel, sudden
movements that may cause trauma, and
exposure to loud sounds and pressure changes
(such as from high altitudes). Immediately
after surgery, the client should lie flat with the
surgical ear facing upward; nose blowing is
permitted but should be done gently and on
one side at a time. The client’s first attempt at
postoperative ambulation should be
supervised to prevent falls caused by vertigo
and light-headedness. The client must avoid
shampooing and swimming to keep the
dressing and the ear dry.
20.Answer C. The most common adverse
reaction to dantrolene is muscle weakness.
The drug also may depress liver function or
cause idiosyncratic hepatitis. Muscle
weakness is rarely severe enough to cause
slurring of speech, drooling, and enuresis.
Although excessive tearing and urine
retention are adverse reactions associated with
dantrolene use, they aren’t as common as
muscle weakness
21.Answer A. Systemic absorption of atropine
sulfate can cause tachycardia, palpitations,
flushing, dry skin, ataxia, and confusion. To
minimize systemic absorption, the client
should apply digital pressure over the
punctum at the inner canthus for 2 to 3
minutes after instilling the drops. The drug
also may cause dry mouth. It isn’t known to
cause hypotension or apnea.
22.Answer B. Because a cervical spine injury
can cause respiratory distress, the nurse
should take immediate action to maintain a
patent airway and provide adequate
oxygenation. The other options may be
appropriate for a client with a spinal cord
injury — particularly during the course of
recovery — but don’t take precedence over a
diagnosis of Ineffective breathing pattern.
23.Answer D. In addition to relieving painful
muscle spasms, diazepam also is
recommended for treatment of spasticity
associated with spinal cord lesions.
Diazepam’s use is limited by its central
nervous system effects and the tolerance that
develops with prolonged use. The parenteral
form of diazepam can treat status epilepticus,
but the drug’s sedating properties make it an
unsuitable choice for long-term management
of epilepsy. Diazepam isn’t an analgesic
agent.
24.Answer C. To elicit the oculocephalic
response, which detects cranial nerve
compression, the nurse turns the client’s head
suddenly while holding the eyelids open.
Normally, the eyes move from side to side
when the head is turned; in an abnormal
response, the eyes remain fixed. The nurse
introduces ice water into the external auditory
canal when testing the oculovestibular
response; normally, the client’s eyes deviate
to the side of ice water introduction. The
nurse touches the client’s cornea with a wisp
of cotton to elicit the corneal reflex response,
which reveals brain stem function; blinking is
the normal response. Shining a bright light
into the client’s pupil helps evaluate brain
stem and cranial nerve III functions; normally,
the pupil responds by constricting.
25.Answer D. The nurse must cautiously
administer pancuronium, succinylcholine, and
any other neuromuscular blocking agent to a
client with myasthenia gravis. Such a client
isn’t less sensitive to the effects of a
neuromuscular blocking agent. Either
succinylcholine or pancuronium can be
 administered in the usual adult dosage to a
client with myasthenia gravis.
26.Answer B. Cones provide daylight color
vision, and their stimulation is interpreted as
color. If one or more types of cones are absent
or defective, color blindness occurs. Rods are
sensitive to low levels of illumination but
can’t discriminate color. The lens is
responsible for focusing images. Aqueous
humor is a clear watery fluid and isn’t
involved with color perception.
27.Answer C. Decerebrate posturing,
characterized by abnormal extension in
response to painful stimuli, indicates damage
to the midbrain. With damage to the
diencephalon or cortex, abnormal flexion
(decorticate posturing) occurs when a painful
stimulus is applied. Damage to the medulla
results in flaccidity.
28.Answer A. Vision changes, such as diplopia,
nystagmus, and blurred vision, are symptoms
of multiple sclerosis. Deep tendon reflexes
may be increased or hyperactive — not
absent. Babinski’s sign may be positive.
Tremors at rest aren’t characteristic of
multiple sclerosis; however, intentional
tremors, or those occurring with purposeful
voluntary movement, are common in clients
with multiple sclerosis. Affected muscles are
spastic, rather than flaccid.
29.Answer D. The headache may be an
indication that the aneurysm is leaking. The
nurse should notify the physician
immediately. Sitting with the client is
appropriate but only after the physician has
been notified of the change in the client’s
condition. The physician will decide whether
or not administration of an analgesic is
indicated. Informing the nurse manager isn’t
necessary.
30.Answer D. Swallowing is a motor function of
cranial nerves IX and X. Cranial nerves I, II,
and VIII don’t possess motor functions. The
motor functions of cranial nerve III include
extraocular eye movement, eyelid elevation,
and pupil constriction. The motor function of
cranial nerve V is chewing. Cranial nerve VI
controls lateral eye movement.
 NCLEX Practice Exam for Neurologic System 2
1. A white female client is admitted to an
acute care facility with a diagnosis of
cerebrovascular accident (CVA). Her
history reveals bronchial asthma,
exogenous obesity, and iron deficiency
anemia. Which history finding is a risk
factor for CVA?
A. Caucasian race
B. Female sex
C. Obesity
D. Bronchial asthma
2. The nurse is teaching a female client
with multiple sclerosis. When teaching the
client how to reduce fatigue, the nurse
should tell the client to:
A. take a hot bath.
B. rest in an air-conditioned room
C. increase the dose of muscle relaxants.
D. avoid naps during the day
3. A male client is having a tonic-clonic
seizures. What should the nurse do first?
A. Elevate the head of the bed.
B. Restrain the client’s arms and legs.
C. Place a tongue blade in the client’s mouth.
D. Take measures to prevent injury.
4. A female client with Guillain-Barré
syndrome has paralysis affecting the
respiratory muscles and requires
mechanical ventilation. When the client
asks the nurse about the paralysis, how
should the nurse respond?
A. “You may have difficulty believing this, but
the paralysis caused by this disease is
temporary.”
B. “You’ll have to accept the fact that you’re
permanently paralyzed. However, you won’t
have any sensory loss.”
C. “It must be hard to accept the permanency of
your paralysis.”
D. “You’ll first regain use of your legs and then
your arms.”
5. The nurse is working on a surgical
floor. The nurse must logroll a male client
following a:
A. laminectomy.
B. thoracotomy.
C. hemorrhoidectomy.
D. cystectomy.
6. A female client with a suspected brain
tumor is scheduled for computed
tomography (CT). What should the nurse
do when preparing the client for this test?
A. Immobilize the neck before the client is
moved onto a stretcher.
B. Determine whether the client is allergic to
iodine, contrast dyes, or shellfish.
C. Place a cap over the client’s head.
D. Administer a sedative as ordered.
7. During a routine physical examination
to assess a male client’s deep tendon
reflexes, the nurse should make sure to:
A. use the pointed end of the reflex hammer
when striking the Achilles tendon.
B. support the joint where the tendon is being
tested.
C. tap the tendon slowly and softly
D. hold the reflex hammer tightly.
8. A female client is admitted in a
disoriented and restless state after
sustaining a concussion during a car
accident. Which nursing diagnosis takes
highest priority in this client’s plan of
care?
A. Disturbed sensory perception (visual)
B. Self-care deficient: Dressing/grooming
C. Impaired verbal communication
D. Risk for injury
9. A female client with amyotrophic lateral
sclerosis (ALS) tells the nurse,
“Sometimes I feel so frustrated. I can’t do
anything without help!” This comment
best supports which nursing diagnosis?
A. Anxiety
B. Powerlessness
C. Ineffective denial
D. Risk for disuse syndrome
10. For a male client with suspected
increased intracranial pressure (ICP), a
most appropriate respiratory goal is to:
A. prevent respiratory alkalosis.
B. lower arterial pH.
C. promote carbon dioxide elimination.
D. maintain partial pressure of arterial oxygen
(PaO2) above 80 mm Hg
 11. Nurse Maureen witnesses a
neighbor’s husband sustain a fall from the
roof of his house. The nurse rushes to the
victim and determines the need to opens
the airway in this victim by using which
method?
A. Flexed position
B. Head tilt-chin lift
C. Jaw thrust maneuver
D. Modified head tilt-chin lift
12. The nurse is assessing the motor
function of an unconscious male client.
The nurse would plan to use which plan
to use which of the following to test the
client’s peripheral response to pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing of the sternocleidomastoid muscle
13. A female client admitted to the
hospital with a neurological problem asks
the nurse whether magnetic resonance
imaging may be done. The nurse
interprets that the client may be ineligible
for this diagnostic procedure based on the
client’s history of:
A. Hypertension
B. Heart failure
C. Prosthetic valve replacement
D. Chronic obstructive pulmonary disorder
14. A male client is having a lumbar
puncture performed. The nurse would
plan to place the client in which position?
A. Side-lying, with a pillow under the hip
B. Prone, with a pillow under the abdomen
C. Prone, in slight-Trendelenburg’s position
D. Side-lying, with the legs pulled up and head
bent down onto chest.
15. The nurse is positioning the female
client with increased intracranial pressure.
Which of the following positions would the
nurse avoid?
A. Head mildline
B. Head turned to the side
C. Neck in neutral position
D. Head of bed elevated 30 to 45 degrees
16. A female client has clear fluid leaking
from the nose following a basilar skull
fracture. The nurse assesses that this is
cerebrospinal fluid if the fluid:
A. Is clear and tests negative for glucose
B. Is grossly bloody in appearance and has a pH
of 6
C. Clumps together on the dressing and has a pH
of 7
D. Separates into concentric rings and test
positive of glucose
17. A male client with a spinal cord injury
is prone to experiencing autonomic
dysreflexia. The nurse would avoid which
of the following measures to minimize the
risk of recurrence?
A. Strict adherence to a bowel retraining program
B. Keeping the linen wrinkle-free under the
client
C. Preventing unnecessary pressure on the lower
limbs
D. Limiting bladder catheterization to once every
12 hours
18. The nurse is caring for the male client
who begins to experience seizure activity
while in bed. Which of the following
actions by the nurse would be
contraindicated?
A. Loosening restrictive clothing
B. Restraining the client’s limbs
C. Removing the pillow and raising padded side
rails
D. Positioning the client to side, if possible, with
the head flexed forward
19. The nurse is assigned to care for a
female client with complete right-sided
hemiparesis. The nurse plans care
knowing that this condition:
A. The client has complete bilateral paralysis of
the arms and legs.
B. The client has weakness on the right side of
the body, including the face and tongue.
C. The client has lost the ability to move the
right arm but is able to walk independently.
D. The client has lost the ability to move the
right arm but is able to walk independently.
20. The client with a brain attack (stroke)
has residual dysphagia. When a diet
 order is initiated, the nurse avoids doing
which of the following?
A. Giving the client thin liquids
B. Thickening liquids to the consistency of
oatmeal
C. Placing food on the unaffected side of the
mouth
D. Allowing plenty of time for chewing and
swallowing
21. The nurse is assessing the adaptation
of the female client to changes in
functional status after a brain attack
(stroke). The nurse assesses that the
client is adapting most successfully if the
client:
A. Gets angry with family if they interrupt a task
B. Experiences bouts of depression and
irritability
C. Has difficulty with using modified feeding
utensils
D. Consistently uses adaptive equipment in
dressing self
22. Nurse Kristine is trying to
communicate with a client with brain
attack (stroke) and aphasia. Which of the
following actions by the nurse would be
least helpful to the client?
A. Speaking to the client at a slower rate
B. Allowing plenty of time for the client to
respond
C. Completing the sentences that the client
cannot finish
D. Looking directly at the client during attempts
at speech
23. A female client has experienced an
episode of myasthenic crisis. The nurse
would assess whether the client has
precipitating factors such as:
A. Getting too little exercise
B. Taking excess medication
C. Omitting doses of medication
D. Increasing intake of fatty foods
24. The nurse is teaching the female
client with myasthenia gravis about the
prevention of myasthenic and cholinergic
crises. The nurse tells the client that this
is most effectively done by:
A. Eating large, well-balanced meals
B. Doing muscle-strengthening exercises
C. Doing all chores early in the day while less
fatigued
D. Taking medications on time to maintain
therapeutic blood levels
25. A male client with Bell’s palsy asks
the nurse what has caused this problem.
The nurse’s response is based on an
understanding that the cause is:
A. Unknown, but possibly includes ischemia,
viral infection, or an autoimmune problem
B. Unknown, but possibly includes long-term
tissue malnutrition and cellular hypoxia
C. Primary genetic in origin, triggered by
exposure to meningitis
D. Primarily genetic in origin, triggered by
exposure to neurotoxins
26. The nurse has given the male client
with Bell’s palsy instructions on
preserving muscle tone in the face and
preventing denervation. The nurse
determines that the client needs
additional information if the client states
that he or she will:
A. Exposure to cold and drafts
B. Massage the face with a gentle upward motion
C. Perform facial exercises
D. Wrinkle the forehead, blow out the cheeks,
and whistle
27. Female client is admitted to the
hospital with a diagnosis of Guillain-Barre
syndrome. The nurse inquires during the
nursing admission interview if the client
has history of:
A. Seizures or trauma to the brain
B. Meningitis during the last 5 years
C. Back injury or trauma to the spinal cord
D. Respiratory or gastrointestinal infection
during the previous month.
28. A female client with Guillian-Barre
syndrome has ascending paralysis and is
intubated and receiving mechanical
ventilation. Which of the following
strategies would the nurse incorporate in
the plan of care to help the client cope
with this illness?
A. Giving client full control over care decisions
and restricting visitors
B. Providing positive feedback and encouraging
active range of motion
C. Providing information, giving positive
feedback, and encouraging relaxation
D. Providing intravaneously administered
sedatives, reducing distractions and limiting
visitors
29. A male client has an impairment of
cranial nerve II. Specific to this
impairment, the nurse would plan to do
which of the following to ensure client to
ensure client safety?
A. Speak loudly to the client
B. Test the temperature of the shower water
C. Check the temperature of the food on the
delivery tray.
D. Provide a clear path for ambulation without
obstacles
30. A female client has a neurological
deficit involving the limbic system.
Specific to this type of deficit, the nurse
would document which of the following
information related to the client’s
behavior.
A. Is disoriented to person, place, and time
B. Affect is flat, with periods of emotional
lability
C. Cannot recall what was eaten for breakfast
today
D. Demonstrate inability to add and subtract;
does not know who is president
Answers and Rationales
1. Answer C. Obesity is a risk factor for CVA.
Other risk factors include a history of
ischemic episodes, cardiovascular disease,
diabetes mellitus, atherosclerosis of the
cranial vessels, hypertension, polycythemia,
smoking, hypercholesterolemia, oral
contraceptive use, emotional stress, family
history of CVA, and advancing age. The
client’s race, sex, and bronchial asthma aren’t
risk factors for CVA
2. Answer B. Fatigue is a common symptom in
clients with multiple sclerosis. Lowering the
body temperature by resting in an air-
conditioned room may relieve fatigue;
however, extreme cold should be avoided. A
hot bath or shower can increase body
temperature, producing fatigue. Muscle
relaxants, prescribed to reduce spasticity, can
cause drowsiness and fatigue. Planning for
frequent rest periods and naps can relieve
fatigue. Other measures to reduce fatigue in
the client with multiple sclerosis include
treating depression, using occupational
therapy to learn energy conservation
techniques, and reducing spasticity.
3. Answer D. Protecting the client from injury is
the immediate priority during a seizure.
Elevating the head of the bed would have no
effect on the client’s condition or safety.
Restraining the client’s arms and legs could
cause injury. Placing a tongue blade or other
object in the client’s mouth could damage the
teeth.
4. Answer A. The nurse should inform the client
that the paralysis that accompanies Guillain-
Barré syndrome is only temporary. Return of
motor function begins proximally and extends
distally in the legs.
5. Answer A. The client who has had spinal
surgery, such as laminectomy, must be
logrolled to keep the spinal column straight
when turning. The client who has had a
thoracotomy or cystectomy may turn himself
or may be assisted into a comfortable position.
Under normal circumstances,
hemorrhoidectomy is an outpatient procedure,
and the client may resume normal activities
immediately after surgery.
6. Answer B. Because CT commonly involves
use of a contrast agent, the nurse should
determine whether the client is allergic to
iodine, contrast dyes, or shellfish. Neck
immobilization is necessary only if the client
has a suspected spinal cord injury. Placing a
cap over the client’s head may lead to
misinterpretation of test results; instead, the
hair should be combed smoothly. The
physician orders a sedative only if the client
can’t be expected to remain still during the CT
scan.
7. Answer B. To prevent the attached muscle
from contracting, the nurse should support the
joint where the tendon is being tested. The
nurse should use the flat, not pointed, end of
the reflex hammer when striking the Achilles
tendon. (The pointed end is used to strike over
small areas, such as the thumb placed over the
biceps tendon.) Tapping the tendon slowly
and softly wouldn’t provoke a deep tendon
reflex response. The nurse should hold the
reflex hammer loosely, not tightly, between
the thumb and fingers so it can swing in an
arc.
8. Answer D. Because the client is disoriented
and restless, the most important nursing
 diagnosis is risk for injury. Although the other
options may be appropriate, they’re secondary
because they don’t immediately affect the
client’s health or safety.
9. Answer B. This comment best supports a
nursing diagnosis of Powerlessness because
ALS may lead to locked-in syndrome,
characterized by an active and functioning
mind locked in a body that can’t perform even
simple daily tasks. Although Anxiety and
Risk for disuse syndrome may be diagnoses
associated with ALS, the client’s comment
specifically refers to an inability to act
autonomously. A diagnosis of Ineffective
denial would be indicated if the client didn’t
seem to perceive the personal relevance of
symptoms or danger.
10.Answer C. The goal of treatment is to prevent
acidemia by eliminating carbon dioxide. That
is because an acid environment in the brain
causes cerebral vessels to dilate and therefore
increases ICP. Preventing respiratory alkalosis
and lowering arterial pH may bring about
acidosis, an undesirable condition in this case.
It isn’t necessary to maintain a PaO2 as high
as 80 mm Hg; 60 mm Hg will adequately
oxygenate most clients.
11.Answer C. If a neck injury is suspected, the
jaw thrust maneuver is used to open the
airway. The head tilt–chin lift maneuver
produces hyperextension of the neck and
could cause complications if a neck injury is
present. A flexed position is an inappropriate
position for opening the airway.
12.Answer B. Motor testing in the unconscious
client can be done only by testing response to
painful stimuli. Nail bed pressure tests a basic
peripheral response. Cerebral responses to
pain are tested using sternal rub, placing
upward pressure on the orbital rim, or
squeezing the clavicle or sternocleidomastoid
muscle.
13.Answer C. The client having a magnetic
resonance imaging scan has all metallic
objects removed because of the magnetic field
generated by the device. A careful history is
obtained to determine whether any metal
objects are inside the client, such as
orthopedic hardware, pacemakers, artificial
heart valves, aneurysm clips, or intrauterine
devices. These may heat up, become
dislodged, or malfunction during this
procedure. The client may be ineligible if
significant risk exists.
14.Answer D. The client undergoing lumbar
puncture is positioned lying on the side, with
the legs pulled up to the abdomen and the
head bent down onto the chest. This position
helps open the spaces between the vertebrae.
15.Answer B. The head of the client with
increased intracranial pressure should be
positioned so the head is in a neutral midline
position. The nurse should avoid flexing or
extending the client’s neck or turning the head
side to side. The head of the bed should be
raised to 30 to 45 degrees. Use of proper
positions promotes venous drainage from the
cranium to keep intracranial pressure down.
16.Answer D. Leakage of cerebrospinal fluid
(CSF) from the ears or nose may accompany
basilar skull fracture. CSF can be
distinguished from other body fluids because
the drainage will separate into bloody and
yellow concentric rings on dressing material,
called a halo sign. The fluid also tests positive
for glucose.
17.Answer D. The most frequent cause of
autonomic dysreflexia is a distended bladder.
Straight catheterization should be done every
4 to 6 hours, and foley catheters should be
checked frequently to prevent kinks in the
tubing. Constipation and fecal impaction are
other causes, so maintaining bowel regularity
is important. Other causes include stimulation
of the skin from tactile, thermal, or painful
stimuli. The nurse administers care to
minimize risk in these areas.
18.Answer B. Nursing actions during a seizure
include providing for privacy, loosening
restrictive clothing, removing the pillow and
raising side rails in the bed, and placing the
client on one side with the head flexed
forward, if possible, to allow the tongue to fall
forward and facilitate drainage. The limbs are
never restrained because the strong muscle
contractions could cause the client harm. If
the client is not in bed when seizure activity
begins, the nurse lowers the client to the floor,
if possible, protects the head from injury, and
moves furniture that may injure the client.
Other aspects of care are as described for the
client who is in bed.
19.Answer B. Hemiparesis is a weakness of one
side of the body that may occur after a stroke.
Complete hemiparesis is weakness of the face
and tongue, arm, and leg on one side.
Complete bilateral paralysis does not occur in
this condition. The client with right-sided
hemiparesis has weakness of the right arm and
 leg and needs assistance with feeding,
bathing, and ambulating.
20.Answer A. Before the client with dysphagia is
started on a diet, the gag and swallow reflexes
must have returned. The client is assisted with
meals as needed and is given ample time to
chew and swallow. Food is placed on the
unaffected side of the mouth. Liquids are
thickened to avoid aspiration.
21.Answer D. Clients are evaluated as coping
successfully with lifestyle changes after a
brain attack (stroke) if they make appropriate
lifestyle alterations, use the assistance of
others, and have appropriate social
interactions. Options A, B, and C are not
adaptive behaviors.
22.Answer C. Clients with aphasia after brain
attack (stroke) often fatigue easily and have a
short attention span. General guidelines when
trying to communicate with the aphasic client
include speaking more slowly and allowing
adequate response time, listening to and
watching attempts to communicate, and trying
to put the client at ease with a caring and
understanding manner. The nurse would avoid
shouting (because the client is not deaf),
appearing rushed for a response, and letting
family members provide all the responses for
the client.
23.Answer C. Myasthenic crisis often is caused
by undermedication and responds to the
administration of cholinergic medications,
such as neostigmine (Prostigmin) and
pyridostigmine (Mestinon). Cholinergic crisis
(the opposite problem) is caused by excess
medication and responds to withholding of
medications. Too little exercise and fatty food
intake are incorrect. Overexertion and
overeating possibly could trigger myasthenic
crisis.
24.Answer D. Clients with myasthenia gravis are
taught to space out activities over the day to
conserve energy and restore muscle strength.
Taking medications correctly to maintain
blood levels that are not too low or too high is
important. Muscle-strengthening exercises are
not helpful and can fatigue the client.
Overeating is a cause of exacerbation of
symptoms, as is exposure to heat, crowds,
erratic sleep habits, and emotional stress.
25.Answer A. Bell’s palsy is a one-sided facial
paralysis from compression of the facial
nerve. The exact cause is unknown, but may
include vascular ischemia, infection, exposure
to viruses such as herpes zoster or herpes
simplex, autoimmune disease, or a
combination of these factors.
26.Answer A. Prevention of muscle atrophy with
Bell’s palsy is accomplished with facial
massage, facial exercises, and electrical
stimulation of the nerves. Exposure to cold or
drafts is avoided. Local application of heat to
the face may improve blood flow and provide
comfort.
27.Answer D. Guillain-Barré syndrome is a
clinical syndrome of unknown origin that
involves cranial and peripheral nerves. Many
clients report a history of respiratory or
gastrointestinal infection in the 1 to 4 weeks
before the onset of neurological deficits.
Occasionally, the syndrome can be triggered
by vaccination or surgery.
28.Answer C. The client with Guillain-Barré
syndrome experiences fear and anxiety from
the ascending paralysis and sudden onset of
the disorder. The nurse can alleviate these
fears by providing accurate information about
the client’s condition, giving expert care and
positive feedback to the client, and
encouraging relaxation and distraction. The
family can become involved with selected
care activities and provide diversion for the
client as well.
29.Answer D. Cranial nerve II is the optic nerve,
which governs vision. The nurse can provide
safety for the visually impaired client by
clearing the path of obstacles when
ambulating. Testing the shower water
temperature would be useful if there were an
impairment of peripheral nerves. Speaking
loudly may help overcome a deficit of cranial
nerve VIII (vestibulocochlear). Cranial nerve
VII (facial) and IX (glossopharyngeal) control
taste from the anterior two thirds and posterior
third of the tongue, respectively.
30.Answer B. The limbic system is responsible
for feelings (affect) and emotions. Calculation
ability and knowledge of current events
relates to function of the frontal lobe. The
cerebral hemispheres, with specific regional
functions, control orientation. Recall of recent
events is controlled by the hippocampus.
 NCLEX Practice Exam for Genitourinary System A. The skin wasn’t lubricated before the pouch
was applied.
1. The nurse is aware that the following B. The pouch faceplate doesn’t fit the stoma.
findings would be further evidence of a C. A skin barrier was applied properly.
urethral injury in a male client during D. Stoma dilation wasn’t performed.
rectal examination? 5. The nurse is aware that the following
laboratory values supports a diagnosis of
A. A low-riding prostate
B. The presence of a boggy mass pyelonephritis?
C. Absent sphincter tone A. Myoglobinuria
D. A positive Hemoccult B. Ketonuria
2. When a female client with an indwelling C. Pyuria
urinary (Foley) catheter insists on walking D. Low white blood cell (WBC) count
to the hospital lobby to visit with family 6. A female client with chronic renal
members, nurse Rose teaches how to do failure (CRF) is receiving a hemodialysis
this without compromising the catheter. treatment. After hemodialysis, nurse
Which client action indicates an accurate Sarah knows that the client is most likely
understanding of this information? to experience:
A. The client sets the drainage bag on the floor A. hematuria.
while sitting down. B. weight loss.
B. The client keeps the drainage bag below the C. increased urine output.
bladder at all times. D. increased blood pressure.
C. The client clamps the catheter drainage tubing 7. Nurse Lea is assessing a male client
while visiting with the family. diagnosed with gonorrhea. Which
D. The client loops the drainage tubing below its
symptom most likely prompted the client
point of entry into the drainage bag.
to seek medical attention?
3. A female client has just been
diagnosed with condylomata acuminata A. Rashes on the palms of the hands and soles of
(genital warts). What information is the feet
appropriate to tell this client? B. Cauliflower-like warts on the penis
C. Painful red papules on the shaft of the penis
A. This condition puts her at a higher risk for D. Foul-smelling discharge from the penis
cervical cancer; therefore, she should have a 8. Nurse Agnes is reviewing the report of
Papanicolaou (Pap) smear annually. a client’s routine urinalysis. Which value
B. The most common treatment is metronidazole
should the nurse consider abnormal?
(Flagyl), which should eradicate the problem
within 7 to 10 days. A. Specific gravity of 1.03
C. The potential for transmission to her sexual B. Urine pH of 3.0
partner will be eliminated if condoms are used C. Absence of protein
every time they have sexual intercourse. D. Absence of glucose
D. The human papillomavirus (HPV), which
9. A male client is scheduled for a renal
causes condylomata acuminata, can’t be
transmitted during oral sex. clearance test. Nurse Maureen should
4. A male client with bladder cancer has explain that this test is done to assess the
had the bladder removed and an ileal kidneys’ ability to remove a substance
conduit created for urine diversion. While from the plasma in:
changing this client’s pouch, the nurse A. 1 minute.
observes that the area around the stoma B. 30 minutes.
is red, weeping, and painful. What should C. 1 hour.
nurse Katrina conclude? D. 24 hours.
10. A male client in the short-procedure
unit is recovering from renal angiography
 in which a femoral puncture site was
used. When providing postprocedure
care, the nurse should:
A. keep the client’s knee on the affected side
bent for 6 hours.
B. apply pressure to the puncture site for 30
minutes.
C. check the client’s pedal pulses frequently.
D. remove the dressing on the puncture site after
vital signs stabilize.
11. A female client is admitted for
treatment of chronic renal failure (CRF).
Nurse Juliet knows that this disorder
increases the client’s risk of:
A. water and sodium retention secondary to a
severe decrease in the glomerular filtration
rate.
B. a decreased serum phosphate level secondary
to kidney failure.
C. an increased serum calcium level secondary to
kidney failure.
D. metabolic alkalosis secondary to retention of
hydrogen ions.
12. Because of difficulties with
hemodialysis, peritoneal dialysis is
initiated to treat a female client’s uremia.
Which finding signals a significant
problem during this procedure?
A. Potassium level of 3.5 mEq/L
B. Hematocrit (HCT) of 35%
C. Blood glucose level of 200 mg/dl
D. White blood cell (WBC) count of
20,000/mm3
13. For a male client in the oliguric phase
of acute renal failure (ARF), which
nursing intervention is most important?
A. Encouraging coughing and deep breathing
B. Promoting carbohydrate intake
C. Limiting fluid intake
D. Providing pain-relief measures
14. A female client requires hemodialysis.
Which of the following drugs should be
withheld before this procedure?
A. Phosphate binders
B. Insulin
C. Antibiotics
D. Cardiac glycosides
15. A client comes to the outpatient
department complaining of vaginal
discharge, dysuria, and genital irritation.
Suspecting a sexually transmitted disease
(STD), Dr. Smith orders diagnostic tests
of the vaginal discharge. Which STD must
be reported to the public health
department?
A. Chlamydia
B. Gonorrhea
C. Genital herpes
D. Human papillomavirus infection
16. A male client with acute pyelonephritis
receives a prescription for co-trimoxazole
(Septra) P.O. twice daily for 10 days.
Which finding best demonstrates that the
client has followed the prescribed
regimen?
A. Urine output increases to 2,000 ml/day.
B. Flank and abdominal discomfort decrease.
C. Bacteria are absent on urine culture.
D. The red blood cell (RBC) count is normal.
17. A 26-year-old female client seeks
care for a possible infection. Her
symptoms include burning on urination
and frequent, urgent voiding of small
amounts of urine. She’s placed on
trimethoprim-sulfamethoxazole (Bactrim)
to treat possible infection. Another
medication is prescribed to decrease the
pain and frequency. Which of the
following is the most likely medication
prescribed?
A. nitrofurantoin (Macrodantin)
B. ibuprofen (Motrin)
C. acetaminophen with codeine
D. phenazopyridine (Pyridium)
18. A triple-lumen indwelling urinary
catheter is inserted for continuous bladder
irrigation following a transurethral
resection of the prostate. In addition to
balloon inflation, the nurse is aware that
the functions of the three lumens include:
A. Continuous inflow and outflow of irrigation
solution.
B. Intermittent inflow and continuous outflow of
irrigation solution.
C. Continuous inflow and intermittent outflow of
irrigation solution.
D. Intermittent flow of irrigation solution and
prevention of hemorrhage.
19. Nurse Claudine is reviewing a client’s
fluid intake and output record. Fluid intake
and urine output should relate in which
way?
A. Fluid intake should be double the urine
output.
B. Fluid intake should be approximately equal to
the urine output.
C. Fluid intake should be half the urine output.
D. Fluid intake should be inversely proportional
to the urine output.
20. After trying to conceive for a year, a
couple consults an infertility specialist.
When obtaining a history from the
husband, nurse Jenny inquires about
childhood infectious diseases. Which
childhood infectious disease most
significantly affects male fertility?
A. Chickenpox
B. Measles
C. Mumps
D. Scarlet fever
21. A male client comes to the emergency
department complaining of sudden onset
of sharp, severe pain in the lumbar
region, which radiates around the side
and toward the bladder. The client also
reports nausea and vomiting and appears
pale, diaphoretic, and anxious. The
physician tentatively diagnoses renal
calculi and orders flat-plate abdominal X-
rays. Renal calculi can form anywhere in
the urinary tract. What is their most
common formation site?
A. Kidney
B. Ureter
C. Bladder
D. Urethra
22. A female client with acute renal failure
is undergoing dialysis for the first time.
The nurse in charge monitors the client
closely for dialysis equilibrium syndrome,
a complication that is most common
during the first few dialysis sessions.
Typically, dialysis equilibrium syndrome
causes:
A. confusion, headache, and seizures.
B. acute bone pain and confusion.
C. weakness, tingling, and cardiac arrhythmias.
D. hypotension, tachycardia, and tachypnea.
23. Dr. Marquez prescribes norfloxacin
(Noroxin), 400 mg P.O. twice daily, for a
client with a urinary tract infection (UTI).
The client asks the nurse how long to
continue taking the drug. For an
uncomplicated UTI, the usual duration of
norfloxacin therapy is:
A. 3 to 5 days.
B. 7 to 10 days.
C. 12 to 14 days.
D. 10 to 21 days.
24. Nurse Joy is providing postprocedure
care for a client who underwent
percutaneous lithotripsy. In this
procedure, an ultrasonic probe inserted
through a nephrostomy tube into the renal
pelvis generates ultra–high-frequency
sound waves to shatter renal calculi. The
nurse should instruct the client to:
A. limit oral fluid intake for 1 to 2 weeks.
B. report the presence of fine, sandlike particles
through the nephrostomy tube.
C. notify the physician about cloudy or foul-
smelling urine.
D. report bright pink urine within 24 hours after
the procedure.
25. A client is frustrated and embarrassed
by urinary incontinence. Which of the
following measures should nurse Bea
include in a bladder retraining program?
A. Establishing a predetermined fluid intake
pattern for the client
B. Encouraging the client to increase the time
between voidings
C. Restricting fluid intake to reduce the need to
void
D. Assessing present elimination patterns
26. After having transurethral resection of
the prostate (TURP), a Mr. Lim returns to
the unit with a three-way indwelling
urinary catheter and continuous closed
 bladder irrigation. Which finding suggests
that the client’s catheter is occluded?
A. The urine in the drainage bag appears red to
pink.
B. The client reports bladder spasms and the urge
to void.
C. The normal saline irrigant is infusing at a rate
of 50 drops/minute. A.
D. About 1,000 ml of irrigant have been instilled; B.
1,200 ml of drainage have been returned. C.
D.
27. Nurse Mary is inserting a urinary
catheter into a client who is extremely
anxious about the procedure. The nurse
can facilitate the insertion by asking the
client to:
A. Encouraging intake of at least 2 L of fluid
A. initiate a stream of urine.
B. breathe deeply.
B. Giving the client a glass of soda before
C. turn to the side.
D. hold the labia or shaft of penis.
C. Taking the client to the bathroom twice per
28. A female adult client admitted with a
gunshot wound to the abdomen is D. Consulting with a dietitian
transferred to the intensive care unit after
an exploratory laparotomy. Which
assessment finding suggests that the
client is experiencing acute renal failure
(ARF)?
A. Blood urea nitrogen (BUN) level of 22 mg/dl
B. Serum creatinine level of 1.2 mg/dl
C. Serum creatinine level of 1.2 mg/dl
A.
D. Urine output of 400 ml/24 hours
B.
29. A 55-year old client with benign C.
prostatic hyperplasia doesn’t respond to D.
medical treatment and is admitted to the
facility for prostate gland removal. Before
providing preoperative and postoperative
instructions to the client, Nurse Gerry
asks the surgeon which prostatectomy
A.
procedure will be done. What is the most
B.
widely used procedure for prostate gland C.
removal? D.
A. Transurethral resection of the prostate
(TURP)
B. Suprapubic prostatectomy
C. Retropubic prostatectomy
D. Transurethral laser incision of the prostate A.
B.
30. A female client with suspected renal
C.
dysfunction is scheduled for excretory D.
urography. Nurse January reviews the
history for conditions that may warrant
changes in client preparation. Normally, a
client should be mildly hypovolemic (fluid
depleted) before excretory urography.
Which history finding would call for the
client to be well hydrated instead?
Cystic fibrosis
Multiple myeloma
Gout
Myasthenia gravis
31. Nurse Karen is caring for a client who
had a cerebrovascular accident (CVA).
Which nursing intervention promotes
urinary continence?
daily
bedtime
day
32. When examining a female client’s
genitourinary system, Nurse Sandy
assesses for tenderness at the
costovertebral angle by placing the left
hand over this area and striking it with the
right fist. Normally, this percussion
technique produces which sound?
A flat sound
A dull sound
Hyperresonance
Tympany
33. A male client with chronic renal failure
has a serum potassium level of 6.8
mEq/L. What should nurse Olivia assess
first?
Blood pressure
Respirations
Temperature
Pulse
34. Nurse Harry is aware that the
following is an appropriate nursing
diagnosis for a client with renal calculi?
Ineffective tissue perfusion
Functional urinary incontinence
Risk for infection
Decreased cardiac output
 35. A male client develops acute renal
failure (ARF) after receiving I.V. therapy
with a nephrotoxic antibiotic. Because the
client’s 24-hour urine output totals 240 ml,
Nurse Billy suspects that the client is at
risk for:
A. cardiac arrhythmia.
B. paresthesia.
C. dehydration.
D. pruritus.
36. After undergoing transurethral
resection of the prostate to treat benign
prostatic hyperplasia, a male client
returns to the room with continuous
bladder irrigation. On the first day after
surgery, the client reports bladder pain.
What should Nurse Anthony do first?
A. Increase the I.V. flow rate.
B. Notify the physician immediately.
C. Assess the irrigation catheter for patency and
drainage.
D. Administer meperidine (Demerol), 50 mg
I.M., as prescribed.
37. When performing a scrotal
examination, Nurse Payne finds a nodule.
What should the nurse do next?
A. Notify the physician.
B. Change the client’s position and repeat the
examination.
C. Perform a rectal examination.
D. Transilluminate the scrotum.
38. A male client who has been treated
for chronic renal failure (CRF) is ready for
discharge. Nurse Billy should reinforce
which dietary instruction?
A. “Be sure to eat meat at every meal.”
B. “Monitor your fruit intake, and eat plenty of
bananas.”
C.  “Increase your carbohydrate intake.”
D. “Drink plenty of fluids, and use a salt
substitute.”
39. Nurse Gil is aware that the following
statements describing urinary
incontinence in the elderly is true?
A. Urinary incontinence is a normal part of
aging.
B. Urinary incontinence isn’t a disease.
C. Urinary incontinence in the elderly can’t be
treated.
D. Urinary incontinence is a disease.
40. The client underwent a transurethral
resection of the prostate gland 24 hours
ago and is on continuous bladder
irrigation. Nurse Yonny is aware that the
following nursing interventions is
appropriate?
A. Tell the client to try to urinate around the
catheter to remove blood clots.
B. Restrict fluids to prevent the client’s bladder
from becoming distended.
C. Prepare to remove the catheter.
D. Use aseptic technique when irrigating the
catheter.
41. A female client with a urinary tract
infection is prescribed co-trimoxazole
(trimethoprim-sulfamethoxazole). Nurse
Dolly should provide which medication
instruction?
A. “Take the medication with food.”
B. “Drink at least eight 8-oz glasses of fluid
daily.”
C. “Avoid taking antacids during co-trimoxazole
therapy.”
D. “Don’t be afraid to go out in the sun.”
42. A male client is admitted for treatment
of glomerulonephritis. On initial
assessment, Nurse Miley detects one of
the classic signs of acute
glomerulonephritis of sudden onset. Such
signs include:
A. generalized edema, especially of the face and
periorbital area.
B. green-tinged urine.
C. moderate to severe hypotension.
D. polyuria.
43. A client reports experiencing vulvar
pruritus. Which assessment factor may
indicate that the client has an infection
caused by Candida albicans?
A. Cottage cheese–like discharge
B. Yellow-green discharge
C. Gray-white discharge
D. Discharge with a fishy odor
44. A 24-year old female client has just
been diagnosed with condylomata
 acuminata (genital warts). What
information is appropriate to tell this
client?
A. This condition puts her at a higher risk for
cervical cancer; therefore, she should have a
Papanicolaou (Pap) smear annually.
B. The most common treatment is metronidazole
(Flagyl), which should eradicate the problem
within 7 to 10 days.
C. The potential for transmission to her sexual
partner will be eliminated if condoms are used
every time they have sexual intercourse.
D. The human papillomavirus (HPV), which
causes condylomata acuminata, can’t be
transmitted during oral sex.
45. Nurse Vic is monitoring the fluid
intake and output of a female client
recovering from an exploratory
laparotomy. Which nursing intervention
would help the client avoid a urinary tract
infection (UTI)?
A. Maintaining a closed indwelling urinary
catheter system and securing the catheter to
the leg
B. Limiting fluid intake to 1 L/day
C. Encouraging the client to use a feminine
deodorant after bathing
D. Encouraging the client to douche once a day
after removal of the indwelling urinary
catheter
46. Nurse Eve is caring for a client who
had a cerebrovascular accident (CVA).
Which nursing intervention promotes
urinary continence?
A. Encouraging intake of at least 2 L of fluid
daily
B. Giving the client a glass of soda before
bedtime
C. Taking the client to the bathroom twice per
day
D. Consulting with a dietitian
47. A female client with an indwelling
urinary catheter is suspected of having a
urinary tract infection. Nurse Angel should
collect a urine specimen for culture and
sensitivity by:
A. disconnecting the tubing from the urinary
catheter and letting the urine flow into a
sterile container.
B. wiping the self-sealing aspiration port with
antiseptic solution and aspirating urine with a
sterile needle.
C. draining urine from the drainage bag into a
sterile container.
D. clamping the tubing for 60 minutes and
inserting a sterile needle into the tubing above
the clamp to aspirate urine.
48. Nurse Grace is assessing a male
client diagnosed with gonorrheA. Which
symptom most likely prompted the client
to seek medical attention?
A. Rashes on the palms of the hands and soles of
the feet
B. Cauliflower-like warts on the penis
C. Painful red papules on the shaft of the penis
D. Foul-smelling discharge from the penis
49. Nurse Erica is planning to administer
a sodium polystyrene sulfonate
(Kayexalate) enema to a client with a
potassium level of 5.9 mEq/L. Correct
administration and the effects of this
enema would include having the client:
A. retain the enema for 30 minutes to allow for
sodium exchange; afterward, the client should
have diarrhea.
B. retain the enema for 30 minutes to allow for
glucose exchange; afterward, the client should
have diarrhea.
C. retain the enema for 60 minutes to allow for
sodium exchange; diarrhea isn’t necessary to
reduce the potassium level.
D. retain the enema for 60 minutes to allow for
glucose exchange; diarrhea isn’t necessary to
reduce the potassium level.
50. When caring for a male client with
acute renal failure (ARF), Nurse Fatrishia
expects to adjust the dosage or dosing
schedule of certain drugs. Which of the
following drugs would not require such
adjustment?
A. acetaminophen (Tylenol)
B. gentamicin sulfate (Garamycin)
C. cyclosporine (Sandimmune)
D. ticarcillin disodium (Ticar)
Answers and Rationales
1. Answer B. When the urethra is ruptured, a
hematoma or collection of blood separates the
two sections of urethra. This may feel like a
boggy mass on rectal examination. Because of
 the rupture and hematoma, the prostate
becomes high riding. A palpable prostate
gland usually indicates a nonurethral injury.
Absent sphincter tone would refer to a spinal
cord injury. The presence of blood would
probably correlate with GI bleeding or a colon
injury.
2. Answer B. To maintain effective drainage,
the client should keep the drainage bag below
the bladder; this allows the urine to flow by
gravity from the bladder to the drainage bag.
The client shouldn’t lay the drainage bag on
the floor because it could become grossly
contaminated. The client shouldn’t clamp the
catheter drainage tubing because this impedes
the flow of urine. To promote drainage, the
client may loop the drainage tubing above —
not below — its point of entry into the
drainage bag.
3. Answer A. Women with condylomata
acuminata are at risk for cancer of the cervix
and vulva. Yearly Pap smears are very
important for early detection. Because
condylomata acuminata is a virus, there is no
permanent cure. Because condylomata
acuminata can occur on the vulva, a condom
won’t protect sexual partners. HPV can be
transmitted to other parts of the body, such as
the mouth, oropharynx, and larynx.
4. Answer B. If the pouch faceplate doesn’t fit
the stoma properly, the skin around the stoma
will be exposed to continuous urine flow from
the stoma, causing excoriation and red,
weeping, and painful skin. A lubricant
shouldn’t be used because it would prevent
the pouch from adhering to the skin. When
properly applied, a skin barrier prevents skin
excoriation. Stoma dilation isn’t performed
with an ileal conduit, although it may be done
with a colostomy if ordered.
5. Answer C. Pyelonephritis is diagnosed by the
presence of leukocytosis, hematuria, pyuria,
and bacteriuria. The client exhibits fever,
chills, and flank pain. Because there is often a
septic picture, the WBC count is more likely
to be high rather than low, as indicated in
option D. Ketonuria indicates a diabetic state.
6. Answer B. Because CRF causes loss of renal
function, the client with this disorder retains
fluid. Hemodialysis removes this fluid,
causing weight loss. Hematuria is unlikely to
follow hemodialysis because the client with
CRF usually forms little or no urine.
Hemodialysis doesn’t increase urine output
because it doesn’t correct the loss of kidney
function, which severely decreases urine
production in this disorder. By removing
fluids, hemodialysis decreases rather than
increases the blood pressure.
7. Answer D. Symptoms of gonorrhea in men
include purulent, foul-smelling drainage from
the penis and painful urination. Rashes on the
palms of the hands and soles of the feet are
symptoms of the secondary stage of syphilis.
Cauliflower-like warts on the penis are a sign
of human papillomavirus. Painful red papules
on the shaft of the penis may be a sign of the
first stage of genital herpes.
8. Answer B. Normal urine pH is 4.5 to 8;
therefore, a urine pH of 3.0 is abnormal. Urine
specific gravity normally ranges from 1.002 to
1.035, making this client’s value normal.
Normally, urine contains no protein, glucose,
ketones, bilirubin, bacteria, casts, or crystals.
Red blood cells should measure 0 to 3 per
high-power field; white blood cells, 0 to 4 per
high-power field. Urine should be clear, its
color ranging from pale yellow to deep amber.
9. Answer A. The renal clearance test
determines the kidneys’ ability to remove a
substance from the plasma in 1 minute. It
doesn’t measure the kidneys’ ability to
remove a substance over a longer period.
10.Answer C. After renal angiography involving
a femoral puncture site, the nurse should
check the client’s pedal pulses frequently to
detect reduced circulation to the feet caused
by vascular injury. The nurse also should
monitor vital signs for evidence of internal
hemorrhage and should observe the puncture
site frequently for fresh bleeding. The client
should be kept on bed rest for several hours so
the puncture site can seal completely. Keeping
the client’s knee bent is unnecessary. By the
time the client returns to the short-procedure
unit, manual pressure over the puncture site is
no longer needed because a pressure dressing
is in place. The nurse shouldn’t remove this
dressing for several hours — and only if
instructed to do so.
11.Answer A. A client with CRF is at risk for
fluid imbalance — dehydration if the kidneys
fail to concentrate urine, or fluid retention if
the kidneys fail to produce urine. Electrolyte
imbalances associated with this disorder result
from the kidneys’ inability to excrete
phosphorus; such imbalances may lead to
hyperphosphatemia with reciprocal
hypocalcemia. CRF may cause metabolic
acidosis, not metabolic alkalosis, secondary to
 inability of the kidneys to excrete hydrogen
ions.
12.Answer D. An increased WBC count
indicates infection, probably resulting from
peritonitis, which may have been caused by
insertion of the peritoneal catheter into the
peritoneal cavity. Peritonitis can cause the
peritoneal membrane to lose its ability to filter
solutes; therefore, peritoneal dialysis would
no longer be a treatment option for this client.
Hyperglycemia occurs during peritoneal
dialysis because of the high glucose content of
the dialysate; it’s readily treatable with
sliding-scale insulin. A potassium level of 3.5
mEq/L can be treated by adding potassium to
the dialysate solution. An HCT of 35% is
lower than normal. However, in this client, the
value isn’t abnormally low because of the
daily blood samplings. A lower HCT is
common in clients with chronic renal failure
because of the lack of erythropoietin.
13.Answer C. During the oliguric phase of ARF,
urine output decreases markedly, possibly
leading to fluid overload. Limiting oral and
I.V. fluid intake can prevent fluid overload
and its complications, such as heart failure
and pulmonary edema. Encouraging coughing
and deep breathing is important for clients
with various respiratory disorders. Promoting
carbohydrate intake may be helpful in ARF
but doesn’t take precedence over fluid
limitation. Controlling pain isn’t important
because ARF rarely causes pain.
14.Answer D. Cardiac glycosides such as
digoxin should be withheld before
hemodialysis. Hypokalemia is one of the
electrolyte shifts that occur during dialysis,
and a hypokalemic client is at risk for
arrhythmias secondary to digitalis toxicity.
Phosphate binders and insulin can be
administered because they aren’t removed
from the blood by dialysis. Some antibiotics
are removed by dialysis and should be
administered after the procedure to ensure
their therapeutic effects. The nurse should
check a formulary to determine whether a
particular antibiotic should be administered
before or after dialysis.
15.Answer B. Gonorrhea must be reported to the
public health department. Chlamydia, genital
herpes, and human papillomavirus infection
aren’t reportable diseases.
16.Answer C. Co-trimoxazole is a sulfonamide
antibiotic used to treat urinary tract infections.
Therefore, absence of bacteria on urine
culture indicates that the drug has achieved its
desired effect. Although flank pain may
decrease as the infection resolves, this isn’t a
reliable indicator of the drug’s effectiveness.
Co-trimoxazole doesn’t affect urine output or
the RBC count.
17.Answer D. Phenazopyridine may be
prescribed in conjunction with an antibiotic
for painful bladder infections to promote
comfort. Because of its local anesthetic action
on the urinary mucosa, phenazopyridine
specifically relieves bladder pain.
Nitrofurantoin is a urinary antiseptic with no
analgesic properties. While ibuprofen and
acetaminophen with codeine are analgesics,
they don’t exert a direct effect on the urinary
mucosa.
18.Answer A. When preparing for continuous
bladder irrigation, a triple-lumen indwelling
urinary catheter is inserted. The three lumens
provide for balloon inflation and continuous
inflow and outflow of irrigation solution.
19.Answer B. Normally, fluid intake is
approximately equal to the urine output. Any
other relationship signals an abnormality. For
example, fluid intake that is double the urine
output indicates fluid retention; fluid intake
that is half the urine output indicates
dehydration. Normally, fluid intake isn’t
inversely proportional to the urine output.
20.Answer C. Mumps is the most significant
childhood infectious disease affecting male
fertility. Chickenpox, measles, and scarlet
fever don’t affect male fertility.
21.Answer A. The most common site of renal
calculi formation is the kidney. Calculi may
travel down the urinary tract with or without
causing damage and may lodge anywhere
along the tract or may stay within the kidney.
The ureter, bladder, and urethra are less
common sites of renal calculi formation.
22.Answer A. Dialysis equilibrium syndrome
causes confusion, a decreasing level of
consciousness, headache, and seizures. These
findings, which may last several days,
probably result from a relative excess of
interstitial or intracellular solutes caused by
rapid solute removal from the blood. The
resultant organ swelling interferes with
normal physiologic functions. To prevent this
syndrome, many dialysis centers keep first-
time sessions short and use a reduced blood
flow rate. Acute bone pain and confusion are
associated with aluminum intoxication,
another potential complication of dialysis.
 Weakness, tingling, and cardiac arrhythmias
suggest hyperkalemia, which is associated
with renal failure. Hypotension, tachycardia,
and tachypnea signal hemorrhage, another
dialysis complication.
23.Answer B. For an uncomplicated UTI,
norfloxacin therapy usually lasts 7 to 10 days.
Taking the drug for less than 7 days wouldn’t
eradicate such an infection. Taking it for more
than 10 days isn’t necessary. Only a client
with a complicated UTI must take norfloxacin
for 10 to 21 days.
24.Answer C. The client should report the
presence of foul-smelling or cloudy urine.
Unless contraindicated, the client should be
instructed to drink large quantities of fluid
each day to flush the kidneys. Sandlike debris
is normal due to residual stone products.
Hematuria is common after lithotripsy.
25.Answer D. The guidelines for initiating
bladder retraining include assessing the
client’s intake patterns, voiding patterns, and
reasons for each accidental voiding. Lowering
the client’s fluid intake won’t reduce or
prevent incontinence. The client should
actually be encouraged to drink 1.5 to 2 L of
water per day. A voiding schedule should be
established after assessment.
26.Answer B. Reports of bladder spasms and the
urge to void suggest that a blood clot may be
occluding the catheter. After TURP, urine
normally appears red to pink, and normal
saline irrigant usually is infused at a rate of 40
to 60 drops/minute or according to facility
protocol. The amount of retained fluid (1,200
ml) should correspond to the amount of
instilled fluid, plus the client’s urine output
(1,000 ml + 200 ml), which reflects catheter
patency.
27.Answer B. When inserting a urinary catheter,
facilitate insertion by asking the client to
breathe deeply. Doing this will relax the
urinary sphincter. Initiating a stream of urine
isn’t recommended during catheter insertion.
Turning to the side or holding the labia or
penis won’t ease insertion, and doing so may
contaminate the sterile field.
28.Answer D. ARF, characterized by abrupt loss
of kidney function, commonly causes oliguria,
which is demonstrated by a urine output of
400 ml/24 hours. A serum creatinine level of
1.2 mg/dl isn’t diagnostic of ARF. A BUN
level of 22 mg/dl or a temperature of 100.2° F
(37.8° C) wouldn’t result from this disorder.
29.Answer A. TURP is the most widely used
procedure for prostate gland removal. Because
it requires no incision, TURP is especially
suitable for men with relatively minor
prostatic enlargements and for those who are
poor surgical risks. Suprapubic prostatectomy,
retropubic prostatectomy, and transurethral
laser incision of the prostate are less common
procedures; they all require an incision.
30.Answer B. Fluid depletion before excretory
urography is contraindicated in clients with
multiple myeloma, severe diabetes mellitus,
and uric acid nephropathy — conditions that
can seriously compromise renal function in
fluid-depleted clients with reduced renal
perfusion. If these clients must undergo
excretory urography, they should be well
hydrated before the test. Cystic fibrosis, gout,
and myasthenia gravis don’t necessitate
changes in client preparation for excretory
urography.
31.Answer A. By encouraging a daily fluid
intake of at least 2 L, the nurse helps fill the
client’s bladder, thereby promoting bladder
retraining by stimulating the urge to void. The
nurse shouldn’t give the client soda before
bedtime; soda acts as a diuretic and may make
the client incontinent. The nurse should take
the client to the bathroom or offer the bedpan
at least every 2 hours throughout the day;
twice per day is insufficient. Consultation
with a dietitian won’t address the problem of
urinary incontinence.
32.Answer B. Percussion over the costovertebral
angle normally produces a dull, thudding
sound, which is soft to moderately loud with a
moderate pitch and duration. This sound
occurs over less dense, mostly fluid-filled
matter, such as the kidneys, liver, and spleen.
In contrast, a flat sound occurs over highly
dense matter such as muscle; hyperresonance
occurs over the air-filled, overinflated lungs
of a client with pulmonary emphysema or the
lungs of a child (because of a thin chest wall);
and tympany occurs over enclosed structures
containing air, such as the stomach and bowel.
33.Answer D. An elevated serum potassium
level may lead to a life-threatening cardiac
arrhythmia, which the nurse can detect
immediately by palpating the pulse. The
client’s blood pressure may change, but only
as a result of the arrhythmia. Therefore, the
nurse should assess blood pressure later. The
nurse also can delay assessing respirations and
 temperature because these aren’t affected by
the serum potassium level.
34.Answer C. Infection can occur with renal
calculi from urine stasis caused by
obstruction. Options A and D aren’t
appropriate for this diagnosis, and retention of
urine usually occurs, rather than incontinence.
35.Answer A. As urine output decreases, the
serum potassium level rises; if it rises
sufficiently, hyperkalemia may occur,
possibly triggering a cardiac arrhythmia.
Hyperkalemia doesn’t cause paresthesia
(sensations of numbness and tingling).
Dehydration doesn’t occur during this oliguric
phase of ARF, although typically it does arise
during the diuretic phase. In a client with
ARF, pruritus results from increased
phosphates and isn’t associated with
hyperkalemia.
36.Answer C. Although postoperative pain is
expected, the nurse should make sure that
other factors, such as an obstructed irrigation
catheter, aren’t the cause of the pain. After
assessing catheter patency, the nurse should
administer an analgesic, such as meperidine,
as prescribed. Increasing the I.V. flow rate
may worsen the pain. Notifying the physician
isn’t necessary unless the pain is severe or
unrelieved by the prescribed medication.
37.Answer D. A nurse who discovers a nodule,
swelling, or other abnormal finding during a
scrotal examination should transilluminate the
scrotum by darkening the room and shining a
flashlight through the scrotum behind the
mass. A scrotum filled with serous fluid
transilluminates as a red glow; a more solid
lesion, such as a hematoma or mass, doesn’t
transilluminate and may appear as a dark
shadow. Although the nurse should notify the
physician of the abnormal finding, performing
transillumination first provides additional
information. The nurse can’t uncover more
information about a scrotal mass by changing
the client’s position and repeating the
examination or by performing a rectal
examination.
38.Answer C. In a client with CRF, unrestricted
intake of sodium, protein, potassium, and
fluid may lead to a dangerous accumulation of
electrolytes and protein metabolic products,
such as amino acids and ammonia. Therefore,
the client must limit intake of sodium; meat,
which is high in protein; bananas, which are
high in potassium; and fluid, because the
failing kidneys can’t secrete adequate urine.
Salt substitutes are high in potassium and
should be avoided. Extra carbohydrates are
needed to prevent protein catabolism.
39.Answer B. Urinary incontinence isn’t a
normal part of aging nor is it a disease. It may
be caused by confusion, dehydration, fecal
impaction, restricted mobility, or other causes.
Certain medications, including diuretics,
hypnotics, sedatives, anticholinergics, and
antihypertensives, may trigger urinary
incontinence. Most clients with urinary
incontinence can be treated; some can be
cured.
40.Answer D. If the catheter is blocked by blood
clots, it may be irrigated according to
physician’s orders or facility protocol. The
nurse should use sterile technique to reduce
the risk of infection. Urinating around the
catheter can cause painful bladder spasms.
Encourage the client to drink fluids to dilute
the urine and maintain urine output. The
catheter remains in place for 2 to 4 days after
surgery and is only removed with a
physician’s order.
41.Answer B. When receiving a sulfonamide
such as co-trimoxazole, the client should
drink at least eight 8-oz glasses of fluid daily
to maintain a urine output of at least 1,500
ml/day. Otherwise, inadequate urine output
may lead to crystalluria or tubular deposits.
For maximum absorption, the client should
take this drug at least 1 hour before or 2 hours
after meals. No evidence indicates that
antacids interfere with the effects of
sulfonamides. To prevent a photosensitivity
reaction, the client should avoid direct
sunlight during co-trimoxazole therapy.
42.Answer A. Generalized edema, especially of
the face and periorbital area, is a classic sign
of acute glomerulonephritis of sudden onset.
Other classic signs and symptoms of this
disorder include hematuria (not green-tinged
urine), proteinuria, fever, chills, weakness,
pallor, anorexia, nausea, and vomiting. The
client also may have moderate to severe
hypertension (not hypotension), oliguria or
anuria (not polyuria), headache, reduced
visual acuity, and abdominal or flank pain.
43.Answer A. The symptoms of C. albicans
include itching and a scant white discharge
that has the consistency of cottage cheese.
Yellow-green discharge is a sign of
Trichomonas vaginalis. Gray-white discharge
and a fishy odor are signs of Gardnerella
vaginalis.
44.Answer A. Women with condylomata 49.Answer A. Kayexalate is a sodium exchange
acuminata are at risk for cancer of the cervix resin. Thus the client will gain sodium as
and vulva. Yearly Pap smears are very potassium is lost in the bowel. For the
important for early detection. Because exchange to occur, Kayexalate must be in
condylomata acuminata is a virus, there is no contact with the bowel for at least 30 minutes.
permanent cure. Because condylomata Sorbitol in the Kayexalate enema causes
acuminata can occur on the vulva, a condom diarrhea, which increases potassium loss and
won’t protect sexual partners. HPV can be decreases the potential for Kayexalate
transmitted to other parts of the body, such as retention.
the mouth, oropharynx, and larynx. 50.Answer A. Because acetaminophen is
45.Answer A. Maintaining a closed indwelling metabolized in the liver, its dosage and dosing
urinary catheter system helps prevent schedule need not be adjusted for a client with
introduction of bacteria; securing the catheter ARF. In contrast, the dosages and schedules
to the client’s leg also decreases the risk of for gentamicin and ticarcillin, which are
infection by helping to prevent urethral metabolized and excreted by the kidney,
trauma. To flush bacteria from the urinary should be adjusted. Because cyclosporine may
tract, the nurse should encourage the client to cause nephrotoxicity, the nurse must monitor
drink at least 10 glasses of fluid daily, if both the dosage and blood drug level in a
possible. Douching and feminine deodorants client receiving this drug.
may irritate the urinary tract and should be
discouraged.
46.Answer A. By encouraging a daily fluid
intake of at least 2 L, the nurse helps fill the
client’s bladder, thereby promoting bladder
retraining by stimulating the urge to void. The
nurse shouldn’t give the client soda before
bedtime; soda acts as a diuretic and may make
the client incontinent. The nurse should take
the client to the bathroom or offer the bedpan
at least every 2 hours throughout the day;
twice per day is insufficient. Consultation
with a dietitian won’t address the problem of
urinary incontinence.
47.Answer B. Most catheters have a self-sealing
port for obtaining a urine specimen.
Antiseptic solution is used to reduce the risk
of introducing microorganisms into the
catheter. Tubing shouldn’t be disconnected
from the urinary catheter. Any break in the
closed urine drainage system may allow the
entry of microorganisms. Urine in urine
drainage bags may not be fresh and may
contain bacteria, giving false test results.
When there is no urine in the tubing, the
catheter may be clamped for no more than 30
minutes to allow urine to collect.
48.Answer D. Symptoms of gonorrhea in men
include purulent, foul-smelling drainage from
the penis and painful urination. Rashes on the
palms of the hands and soles of the feet are
symptoms of the secondary stage of syphilis.
Cauliflower-like warts on the penis are a sign
of human papillomavirus. Painful red papules
on the shaft of the penis may be a sign of the
first stage of genital herpes.