Comprehensive NCLEX-RN Practice Exam

#4 latest edition 2024

1. Question

Category: Management of Care

Which action(s) should you delegate to the experienced nursing assistant when
caring for a patient with a thrombotic stroke with residual left-sided
weakness? Select all that apply.

• A. Assist the patient to reposition every 2 hours.

• B. Reapply pneumatic compression boots.

• C. Remind the patient to perform active ROM.

• D. Check extremities for redness and edema.

Correct Answer: A, B, & C.
The experienced nursing assistant would know how to reposition the patient and
how to reapply compression boots and would remind the patient to perform
activities he has been taught to perform.
• Option D: Assessing for redness and swelling (signs of deep venous
thrombosis {DVT}) requires additional education and is still
appropriate to the professional nurse.
2. Question

Category: Management of Care

The patient who had a stroke needs to be fed. What instruction should you give
to the nursing assistant who will feed the patient?

• A. Position the patient sitting up in bed before you feed her.

• B. Check the patient’s gag and swallowing reflexes.

• C. Feed the patient quickly because there are three more waiting.
 • D. Suction the patient’s secretions between bites of food.
Correct Answer: A. Position the patient sitting up in bed before you feed
her.
Positioning the patient in a sitting position decreases the risk of aspiration.
• Option B: The nursing assistant is not trained to assess gag or
swallowing reflexes.
• Option C: The patient should not be rushed during feeding.
• Option D: A patient who needs to be suctioned between bites of
food is not handling secretions and is at risk for aspiration. This
patient should be assessed further before feeding.
3. Question

Category: Physiological Adaptation

You have just admitted a patient with bacterial meningitis to the medical-surgical
unit. The patient complains of a severe headache with photophobia and has a
temperature of 102.60 F orally. Which collaborative intervention must be
accomplished first?

• A. Administer codeine 15 mg orally for the patient’s headache.

• B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the infection.

• C. Give acetaminophen (Tylenol) 650 mg orally to reduce the fever.

• D. Give furosemide (Lasix) 40 mg IV to decrease intracranial pressure.

Correct Answer: B. Infuse ceftriaxone (Rocephin) 2000 mg IV to treat the
infection.
Untreated bacterial meningitis has a mortality rate approaching 100%, so rapid
antibiotic treatment is essential.
• Option A: Pain medications may be given after treating the infection
that is most probably causing it.
• Option C: Acetaminophen should be given to decrease the fever
after administering the antibiotics first.
• Option D: Furosemide will help reduce CNS stimulation and
irritation and should be implemented as soon as possible.
4. Question

Category: Management of Care

You are mentoring a student nurse in the intensive care unit (ICU) while caring for
a patient with meningococcal meningitis. Which action by the student requires
that you intervene immediately?

• A. The student enters the room without putting on a mask and gown.

• B. The student instructs the family that visits are restricted to 10

minutes.

• C. The student gives the patient a warm blanket when he says he feels
cold.

• D. The student checks the patient’s pupil response to light every 30

minutes.
Correct Answer: A. The student enters the room without putting on a mask
and gown.
Meningococcal meningitis is spread through contact with respiratory secretions
so use of a mask and gown is required to prevent the spread of the infection to
staff members or other patients. The other actions may not be appropriate but
they do not require intervention as rapidly.
• Option B: The presence of a family member at the bedside may
decrease patient confusion and agitation.
• Option C: Patients with hyperthermia frequently complain of feeling
chilled, but warming the patient is not an appropriate intervention.
• Option D: Checking the pupil response to light is appropriate, but it
is not needed every 30 minutes and is uncomfortable for a patient
with photophobia. Focus: Prioritization
5. Question

Category: Management of Care

A 23-year-old patient with a recent history of encephalitis is admitted to the
medical unit with new-onset generalized tonic-clonic seizures. Which nursing
activities included in the patient’s care will be best to delegate to an LPN/LVN
whom you are supervising? Select all that apply.

• A. Document the onset time, nature of seizure activity, and postictal

behaviors for all seizures.
 • B. Administer phenytoin (Dilantin) 200 mg PO daily.

• C. Teach the patient about the need for good oral hygiene.

• D. Develop a discharge plan, including physician visits and referral to

the Epilepsy Foundation.

• E. Gather information about the seizure activity

Correct Answer: B & E
Administration of medications that are not a high risk is included in LPN
education and scope of practice. Collection of data about the seizure activity may
be accomplished by an LPN/LVN who observes initial seizure activity. An
LPN/LVN would know to call the supervising RN immediately if a patient started
to seize.
• Option A: Documentation is a nursing responsibility.
• Option C: Patient education must be accomplished by the registered
nurse because it is within their scope of practice.
• Option D: Planning of care is a complex activity that requires RN
level education and scope of practice.
6. Question

Category: Physiological Adaptation

While working in the ICU, you are assigned to care for a patient with a seizure
disorder. Which of these nursing actions will you implement first if the patient
has a seizure?

• A. Place the patient on a non-rebreather mask will the oxygen at 15

L/minute.

• B. Administer lorazepam (Ativan) 1 mg IV.

• C. Turn the patient to the side and protect the airway.

• D. Assess level of consciousness during and immediately after the

seizure.
Correct Answer: C. Turn the patient to the side and protect the airway.
The priority action during a generalized tonic-clonic seizure is to protect the
airway.
 • Option B: Administration of lorazepam should be the next action
since it will act rapidly to control the seizure.
• Option A: Although oxygen may be useful during the postictal
phase, the hypoxemia during tonic-clonic seizures is caused by
apnea.
• Option D: Checking the level of consciousness is not appropriate
during the seizure, because generalized tonic-clonic seizures are
associated with a loss of consciousness.
7. Question

Category: Pharmacological and Parenteral Therapies

A patient recently started on phenytoin (Dilantin) to control simple complex
seizures is seen in the outpatient clinic. Which information obtained during his
chart review and assessment will be of greatest concern?

• A. The gums appear enlarged and inflamed.

• B. The white blood cell count is 2300/mm3.

• C. Patient occasionally forgets to take the phenytoin until after lunch.

• D. Patient wants to renew his driver’s license next month.

Correct Answer: B. The white blood cell count is 2300/mm3.
Leukopenia is a serious adverse effect of phenytoin and would require
discontinuation of the medication.
• Option A: Inflammation of the gums should be reported to the
physician, but it does not require immediate attention.
• Option C: The nurse should include in the patient teaching the
importance of taking medications on time to avoid episodes of
seizure.
• Option D: Driving is prohibited for a client with a seizure disorder.
This should be included in the patient’s teaching, but will not require
a change in medical treatment for the seizures.
8. Question

Category: Management of Care

After receiving a change-of-shift report at 7:00 AM, which of these patients will
you assess first?
 • A. A 23-year-old with a migraine headache who is complaining of
severe nausea associated with retching.

• B. A 45-year-old who is scheduled for a craniotomy in 30 minutes and

needs preoperative teaching.

• C. A 59-year-old with Parkinson’s disease who will need a swallowing

assessment before breakfast.

• D. A 63-year-old with multiple sclerosis who has an oral temperature of

101.80 F and flank pain.
Correct Answer: D. A 63-year-old with multiple sclerosis who has an oral
temperature of 101.80 F and flank pain.
Urinary tract infections are a frequent complication in patients with multiple
sclerosis because of the effect on bladder function. The elevated temperature and
decreased breath sounds suggest that this patient may have pyelonephritis. The
physician should be notified immediately so that antibiotic therapy can be started
quickly.
• Option A: This patient needs further assessment, but does not
require immediate attention. A migraine can cause severe throbbing
pain or a pulsing sensation, usually on one side of the head. It’s
often accompanied by nausea, vomiting, and extreme sensitivity to
light and sound. Migraine attacks can last for hours to days, and the
pain can be so severe that it interferes with daily activities.
• Option B: Preoperative teaching must be done but it is not the
nurse’s priority. A craniotomy is the surgical removal of part of the
bone from the skull to expose the brain. Specialized tools are used
to remove the section of bone called the bone flap. The bone flap is
temporarily removed, then replaced after the brain surgery has been
done.
• Option C: The patient should be assessed soon, but does not have
an urgent need. In MS, the immune system attacks the protective
sheath (myelin) that covers nerve fibers and causes communication
problems between your brain and the rest of your body. Eventually,
the disease can cause permanent damage or deterioration of the
nerves.
9. Question
Category: Management of Care
All of these nursing activities are included in the care plan for a 78-year-old man
with Parkinson’s disease who has been referred to your home health agency.
Which ones will you delegate to a nursing assistant (NA)? Select all that apply.

• A. Check for orthostatic changes in pulse and blood pressure.

• B. Monitor for improvement in tremor after levodopa (L-dopa) is given.

• C. Remind the patient to allow adequate time for meals.

• D. Monitor for abnormal involuntary jerky movements of extremities.

• E. Assist the patient with prescribed strengthening exercises.

• F. Adapt the patient’s preferred activities to his level of function.

Correct Answer: A, C, & E
NA education and scope of practice includes taking pulse and blood pressure
measurements. In addition, NAs can reinforce previous teaching or skills taught
by the RN or other disciplines, such as speech or physical therapists.
• Option B: Evaluation of patient response to medication requires the
knowledge of an experienced RN.
• Option D: Development and individualizing the plan of care require
RN-level education and scope of practice.
10. Question

Category: Management of Care

As the manager in a long-term-care (LTC) facility, you are in charge of developing
a standard plan of care for residents with Alzheimer’s disease. Which of these
nursing tasks is best to delegate to the LPN team leaders working in the facility?

• A. Check for improvement in resident memory after medication

therapy is initiated.

• B. Use the Mini-Mental State Examination to assess residents every 6

months.

• C. Assist residents to the toilet every 2 hours to decrease the risk for
urinary intolerance.
 • D. Develop individualized activity plans after consulting with residents
and family.
Correct Answer: A. Check for improvement in resident memory after
medication therapy is initiated.
LPN education and team leader responsibilities include checking for the
therapeutic and adverse effects of medications. Changes in the residents’
memory would be communicated to the RN supervisor, who is responsible for
overseeing the plan of care for each resident.
• Option B: Assessment for changes on the Mini-Mental State
Examination is an RN responsibility.
• Option C: Assisting residents with personal care and hygiene would
be delegated to nursing assistants working in the LTC facility.
• Option D: Developing an activity plan should be done by an RN.

11. Question

Category: Basic Care and Comfort

An 89-year-old female patient who has been admitted to the medical unit with
new-onset angina also has a diagnosis of Alzheimer’s disease. The patient’s
husband reports to you that he rarely gets a good night’s sleep because he needs
to make sure his wife does not wander during the night. He insists on checking
each of the medications you give her to be sure they are the same as the ones
she takes at home. Based on this information, which nursing diagnosis
is most appropriate for this patient?

• A. Decreased Cardiac Output related to poor myocardial contractility

• B. Caregiver Role Strain related to continuous need for providing care

• C. Ineffective Therapeutic Regimen Management related to poor

patient memory

• D. Risk for Falls related to patient wandering behavior during the night
Correct Answer: B. Caregiver Role Strain related to continuous need for
providing care
The husband’s statement about lack of sleep and anxiety over whether the
patient is receiving the correct medications are behaviors that support this
diagnosis.
 • Option A: There is no evidence that the patient’s cardiac output is
decreased. Alzheimer?s disease and HF often occur together and
thus increase the cost of care and health resource utilization; this
highlights the need to investigate the relationship between these
two conditions. Impaired cognition in HF patients leads to
significantly more frequent hospital readmissions and increases
mortality rates.
• Option C: Ineffective Therapeutic Regimen Management is not a
priority as based on the statement.
• Option D: Risk for falls is not the priority at this time. Falls are a
leading cause of broken hips and other serious injuries in the elderly,
and those with Alzheimer’s are at particularly high risk of falling.
Problems with vision, perception, and balance increase as
Alzheimer’s advances, making the risk of a fall more likely.
12. Question

Category: Pharmacological and Parenteral Therapies

You are caring for a patient with recurrent glioblastoma who is receiving
dexamethasone (Decadron) 4 mg IV every 6 hours to relieve symptoms of right
arm weakness and headache. Which assessment information concerns you
the most?

• A. The patient does not recognize family members.

• B. The blood glucose level is 234 mg/dL.

• C. The patient complains of a continued headache.

• D. The daily weight has increased 1 kg.

Correct Answer: A. The patient does not recognize family members.
The inability to recognize a family member is a new neurologic deficit for this
patient, and indicates a possible increase in intracranial pressure (ICP). This
change should be communicated to the physician immediately so that treatment
can be initiated.
• Option B: Increased blood glucose levels is an expected side effect
but not an emergency.
• Option C: The continued headache also indicates that the ICP may
be elevated, but it is not a new problem.
 • Option D: The weight gain is a common adverse effect of
dexamethasone that may require treatment, but is not an
emergency.
13. Question

Category: Management of Care

A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence
is admitted to the hospital ED. His wife tells you that he fell down the stairs about
a month ago, but “he didn’t have a scratch afterward.” She feels that he has
become gradually less active and sleepier over the last 10 days or so. Which of
the following collaborative interventions will you implement first?

• A. Place on the hospital alcohol withdrawal protocol.

• B. Transfer to radiology for a CT scan.

• C. Insert a retention catheter to straight drainage.

• D. Give phenytoin (Dilantin) 100 mg PO.

Correct Answer: B. Transfer to radiology for a CT scan.
The patient’s history and assessment data indicate that he may have a chronic
subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the
patient to surgery to have the hematoma evacuated.
• Option A: This can be done after the treatment for any intracranial
lesion has been implemented.
• Option C: This intervention should be done but is not the priority.
• Option D: Administration of phenytoin should be implemented as
soon as possible, but the initial nursing activities should be directed
toward treatment of any intracranial lesion.
14. Question

Category: Management of Care

Which of these patients in the neurologic ICU will be best to assign to an RN who
has floated from the medical unit?

• A. A 26-year-old patient with a basilar skull structure who has clear

drainage coming out of the nose.
 • B. A 42-year-old patient admitted several hours ago with a headache
and diagnosed with a ruptured berry aneurysm.

• C. A 46-year-old patient who was admitted 48 hours ago with bacterial

meningitis and has an antibiotic dose due.

• D. A 65-year-old patient with an astrocytoma who has just returned to

the unit after having a craniotomy.
Correct Answer: C. A 46-year-old patient who was admitted 48 hours ago
with bacterial meningitis and has an antibiotic dose due.
This patient is the most stable of the patients listed. An RN from the medical unit
would be familiar with administration of IV antibiotics.
• Option A: This patient may need the attention of an experienced
neurologic RN.
• Option B: A rupture of an aneurysm is fatal and should be assigned
to a more experienced RN.
• Option D: This patient requires assessment and care from RNs more
experienced in caring for patients with neurologic diagnoses.
15. Question

Category: Physiological Adaptation

What is the priority nursing diagnosis for a patient experiencing a migraine
headache?

• A. Acute pain related to biologic and chemical factors

• B. Anxiety related to change in or threat to health status

• C. Hopelessness related to deteriorating physiological condition

• D. Risk for Side effects related to medical therapy

Correct Answer: A. Acute pain related to biologic and chemical factors
The priority for interdisciplinary care for the patient experiencing a migraine
headache is pain management.
• Option B: Anxiety is a correct diagnosis, but it is not the priority.
Tension headaches are common for people that struggle with severe
anxiety or anxiety disorders. Tension headaches can be described as
a heavy head, migraine, head pressure, or feeling like there is a tight
 band wrapped around their head. These headaches are due to a
tightening of the neck and scalp muscles.
• Option C: Hopelessness should be addressed as part of the nursing
care plan, but it does not require urgency. Hopelessness can result
when someone is going through difficult times or unpleasant
experiences. A person may feel overwhelmed, trapped, or insecure,
or may have a lot of self-doubts due to multiple stresses and losses.
He or she might think that challenges are unconquerable or that
there are no solutions to the problems and may not be able to
mobilize the energy needed to act on his or her own behalf.
• Option D: The risk for side effects is accurate, but it is not as urgent
as the issue of pain, which is often incapacitating. Focus:
Prioritization
16. Question

Category: Reduction of Risk Potential

Nurse Michelle should know that the drainage is normal four (4) days after a
sigmoid colostomy when the stool is:

• A. Green liquid

• B. Solid formed

• C. Loose, bloody

• D. Semiformed
Correct Answer: C. Loose, bloody
Normal bowel function and soft-formed stool usually do not occur until around
the seventh day following surgery. The stool consistency is related to how much
water is being absorbed.
• Option A: Food, medicines, and other things ingested can affect the
consistency or color of the stool.
• Option B: A formed stool may occur a week after the surgery.
• Option D: The stool from a colostomy can be thin or thick liquid, or
semiformed.
17. Question

Category: Physiological Adaptation

Where would nurse Kristine place the call light for a male client with a right-sided
brain attack and left homonymous hemianopsia?

• A. On the client’s right side

• B. On the client’s left side

• C. Directly in front of the client

• D. Where the client like

Correct Answer: A. On the client’s right side
The client has left visual field blindness. The client will see only from the right
side. Homonymous hemianopsia is a condition in which a person sees only one
side?right or left?of the visual world of each eye. The person may not be aware
that the vision loss is happening in both eyes, not just one. An injury to the right
part of the brain produces loss of the left side of the visual world of each eye.
• Option B: The client would not be able to see the call light on his
right side because he can only see the left side.
• Option C: Only the right half of the visual world can be seen by the
client.
• Option D: The most ideal place to put the call light is on the client’s
right side to avoid any injuries.
18. Question

Category: Physiological Adaptation

A male client is admitted to the emergency department following an accident.
What are the first nursing actions of the nurse?

• A. Check respiration, circulation, neurological response

• B. Align the spine, check pupils, and check for hemorrhage

• C. Check respirations, stabilize the spine, and check the circulation

• D. Assess level of consciousness and circulation

Correct Answer: C. Check respirations, stabilize the spine, and check the
circulation
Checking the airway would be the priority, and a neck injury should be suspected.
Airway patency and adequate respiratory effort are both essential for normal
oxygenation and ventilation within the body so that normal physiological
processes can proceed without metabolic derangement.
• Option A: These assessments should be made, but keeping the
spine stable is also a priority since the patient has been in an
accident.
• Option B: The first priority is always to check the airway, then the
rest of the assessments would follow. Patency is assessed through
the presence/absence of obstructive symptoms or findings
suggesting an airway that may become obstructed.
• Option D: The level of consciousness and circulation can be
assessed after securing a patent airway.
19. Question

Category: Pharmacological and Parenteral Therapies

In evaluating the effect of nitroglycerin, Nurse Arthur should know that it reduces
preload and relieves angina by:

• A. Increasing contractility and slowing heart rate

• B. Increasing AV conduction and heart rate

• C. Decreasing contractility and oxygen consumption

• D. Decreasing venous return through vasodilation

Correct Answer: D. Decreasing venous return through vasodilation.
The significant effect of nitroglycerin is vasodilation and decreased venous return,
so the heart does not have to work hard.
• Option A: Nitroglycerin does not increase contractility. Cardiac work
is decreased by venodilation, reducing anginal symptoms secondary
to demand ischemia.
• Option B: AV conduction is not increased through nitroglycerin, and
an increased heart may increase the blood pressure, which is
contrary to the desired effects of nitroglycerin,
• Option C: Contractility is not significantly affected by nitroglycerin.
The desired vasodilatory effect increases perfusion and does not
directly reduce oxygen consumption.
20. Question

Category: Physiological Adaptation

Nurse Patricia finds a female client who is post-myocardial infarction (MI)
slumped on the side rails of the bed and unresponsive to shaking or shouting.
Which is the nurse’s next action?

• A. Call for help and note the time

• B. Clear the airway

• C. Give two sharp thumps to the precordium and check the pulse

• D. Administer two quick blows

Correct Answer: A. Call for help and note the time
Having established, by stimulating the client, that the client is unconscious rather
than sleep, the nurse should immediately call for help. This may be done by
dialing the operator from the client’s phone and giving the hospital code for
cardiac arrest and the client’s room number to the operator, or if the phone is not
available, by pulling the emergency call button. Noting the time is important
baseline information for cardiac arrest procedures.
• Option B: A patent airway has been established the moment the
nurse declares that the client is unconscious and calls for help.
• Option C: This action can be done if there is an unwitnessed,
unmonitored, unstable ventricular tachycardia when a defibrillator is
not immediately available.
• Option D: Administering two quick blows to the precordium is less
effective and its use is more limited ideally.
21. Question

Category: Physiological Adaptation

Nurse Monett is caring for a client recovering from gastrointestinal bleeding. The
nurse should:

• A. Plan care so the client can receive 8 hours of uninterrupted sleep

each night.

• B. Monitor vital signs every 2 hours.

• C. Make sure that the client takes food and medications at prescribed
intervals.
 • D. Provide milk every 2 to 3 hours.
Correct Answer: C. Make sure that the client takes food and medications at
prescribed intervals.
Food and drug therapy will prevent the accumulation of hydrochloric acid or will
neutralize and buffer the acid that does accumulate.
• Option A: Uninterrupted sleep for 8 hours is good, but it does not
directly affect the production of acid.
• Option B: Monitoring vital signs every 2 hours is unnecessary. It can
be monitored every shift or every 4 hours.
• Option D: Milk could aggravate the production of hydrochloric acid.
The nutrients in milk, particularly fat, may stimulate the stomach to
produce more acid.
22. Question

Category: Pharmacological and Parenteral Therapies

A male client was on warfarin (Coumadin) before admission and has been
receiving heparin I.V. for 2 days. The partial thromboplastin time (PTT) is 68
seconds. What should Nurse Carla do?

• A. Stop the I.V. infusion of heparin and notify the physician.

• B. Continue treatment as ordered.

• C. Expect the warfarin to increase the PTT.

• D. Increase the dosage, because the level is lower than normal.

Correct Answer: B. Continue treatment as ordered.
The effects of heparin are monitored by the PTT is normally 30 to 45 seconds; the
therapeutic level is 1.5 to 2 times the normal level.
• Option A: There is no need to stop the infusion since the PTT is at a
therapeutic level. In patients receiving concomitant heparin and
warfarin therapy, PTT reflects the combined effects of both drugs.
Because of the marked effect of warfarin on the PTT, decreasing
heparin dose in response to a high PTT frequently results in
subtherapeutic heparin levels.
• Option C: The PTT is not used to monitor warfarin therapy, but PTT
may be prolonged by warfarin at high doses.
 • Option D: The level is correct; increasing the dosage is unnecessary.
Warfarin markedly affects PTT, for each increase of 1.0 in the
international normalized ratio, the PTT increases 16 seconds.

23. Question

Category: Physiological Adaptation

A client underwent ileostomy, when should the drainage appliance be applied to
the stoma?

• A. 24 hours later, when edema has subsided

• B. In the operating room

• C. After the ileostomy begins to function

• D. When the client is able to begin self-care procedures

Correct Answer: B. In the operating room
The stoma drainage bag is applied in the operating room. Drainage from the
ileostomy contains secretions that are rich in digestive enzymes and highly
irritating to the skin. Protection of the skin from the effects of these enzymes is
begun at once. Skin exposed to these enzymes even for a short time becomes
reddened, painful, and excoriated.
• Option A: If the application of the drainage appliance is delayed
after surgery, the skin around the stoma would be most likely
irritated and damaged due to the digestive enzymes present in the
secretions of the drainage.
• Option C: An ileostomy needs a drainage bag before it starts to
function so that the secretions from the drainage would be caught
up by the bag, preventing contamination of the skin.
• Option D: The client would have irritated, damaged skin once the
drainage comes out from the stoma and comes into contact with the
skin.
24. Question

Category: Reduction of Risk Potential

A client has undergone spinal anesthetic, it will be important that the nurse
immediately position the client in:
 • A. On the side, to prevent obstruction of the airway by the tongue

• B. Flat on back

• C. On the back, with knees, flexed 15 degrees

• D. Flat on the stomach, with the head, turned to the side

Correct Answer: B. Flat on back
To avoid the complication of a painful spinal headache that can last for several
days, the client is kept flat in a supine position for approximately 4 to 12 hours
postoperatively. Headaches are believed to be caused by the seepage of
cerebrospinal fluid from the puncture site. By keeping the client flat, cerebral
spinal fluid pressures are equalized, which avoids trauma to the neurons.
• Option A: The client may experience a severe headache if kept in a
side-lying position. Spinal headaches are caused by leakage of spinal
fluid through a puncture hole in the tough membrane (dura mater)
that surrounds the spinal cord.
• Option C: A supine position for 4 to 12 hours would prevent
seepage of cerebrospinal fluid from the puncture site. There is no
need to flex the knees.
• Option D: Lying on his stomach would be uncomfortable to a
postoperative patient, and would cause a painful spinal headache
from the spinal anesthesia.
25. Question

Category: Physiological Adaptation

While monitoring a male client several hours after a motor vehicle accident,
which assessment data suggest increasing intracranial pressure?

• A. Blood pressure has decreased from 160/90 to 110/70.

• B. Pulse is increased from 87 to 95, with an occasional skipped beat.

• C. The client is oriented when aroused from sleep and goes back to
sleep immediately.

• D. The client refuses dinner because of anorexia.

Correct Answer: C. The client is oriented when aroused from sleep and goes
back to sleep immediately.
This finding suggests that the level of consciousness is decreasing.
• Option A: A blood pressure level of 110/70 mmHg is within normal
limits. Increased intracranial pressure is caused by an increase in
blood pressure.
• Option B: A pulse rate of 95 bpm is within the normal range. When
arterial blood pressure exceeds the intracranial pressure, blood flow
to the brain is restored. The increased arterial blood pressure caused
by the CNS ischemic response stimulates the baroceptors in the
carotid bodies, thus slowing the heart rate drastically often to the
point of bradycardia.
• Option D: Anorexia is not related to increased intracranial pressure.
Anorexia is an eating disorder characterized by abnormally low body
weight, an intense fear of gaining weight, and a distorted perception
of weight.
26. Question

Category: Physiological Adaptation

Mrs. Cruz, 80 years old is diagnosed with pneumonia. Which of the following
symptoms may appear first?

• A. Altered mental status and dehydration

• B. Fever and chills

• C. Hemoptysis and Dyspnea

• D. Pleuritic chest pain and cough

Correct Answer: A. Altered mental status and dehydration
Elderly clients may first appear with only an altered mental status and
dehydration due to a blunted immune response.
• Option B: Fever and chills are classic signs of pneumonia that may
appear later in the elderly. The inflammatory response results in a
proliferation of neutrophils. This can damage lung tissue, leading to
fibrosis and pulmonary edema, which also impairs lung expansion.
• Option C: Hemoptysis is a late sign of pneumonia. Bleeding in the
lungs may originate from bronchial arteries, pulmonary arteries,
bronchial capillaries, and alveolar capillaries. Dyspnea may occur
early, especially among the elderly. Swelling and mucus can make it
 harder to move air through the airways, making it harder to breathe.
This leads to shortness of breath, difficulty of breathing, and feeling
more tired than normal.
• Option D: Cough and pleuritic chest pain are the common
symptoms of pneumonia. The air sacs may fill with fluid or pus,
causing cough with phlegm or ous, fever, chills, and difficulty
breathing.
27. Question

Category: Physiological Adaptation

A male client has active tuberculosis (TB). Which of the following symptoms will
be exhibited?

• A. Chest and lower back pain

• B. Chills, fever, night sweats, and hemoptysis

• C. Fever of more than 104°F (40°C) and nausea

• D. Headache and photophobia

Correct Answer: B. Chills, fever, night sweats, and hemoptysis
Typical signs and symptoms are chills, fever, night sweats, and hemoptysis.
• Option A: Chest pain may be present from coughing but isn’t usual.
Pleurisy is a condition where there is inflammation or irritation of the
lining of the lungs and chest. There is a sharp pain felt when
breathing, coughing, or sneezing.
• Option C: Clients with TB typically have low-grade fevers, not higher
than 102°F (38.9°C). Fever typically develops in the late afternoon or
evening in 68% of the cases, and this typical fever is significantly
more common in patients less 60 years of age.
• Option D: Nausea, headache, and photophobia aren’t usual TB
symptoms. Typical symptoms include a cough that lasts for more
than 3 weeks, loss of appetite and unintentional weight loss, fever,
chills, and night sweats.
28. Question

Category: Physiological Adaptation

Mark, a 7-year-old client, is brought to the emergency department. He’s
tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and has a
nonproductive cough. He recently had a cold. Form this history; the client may
have which of the following conditions?

• A. Acute asthma

• B. Bronchial pneumonia

• C. Chronic obstructive pulmonary disease (COPD)

• D. Emphysema
Correct Answer: A. Acute asthma
Based on the client’s history and symptoms, acute asthma is the most likely
diagnosis.
• Option B: Bronchial pneumonia most often exhibits a productive
cough. It is the type of pneumonia that affects the bronchi in the
lungs. This condition commonly results from a bacterial infection, but
viral and fungal infections can also cause it.
• Option C: COPD commonly occurs in middle-aged people, mostly
over the age of 40. Chronic obstructive pulmonary disease is a
chronic inflammatory lung disease that causes obstructed airflow
from the lungs.
• Option D: Emphysema is most common in men between the ages of
50 and 70. It is a lung condition that causes shortness of breath. The
air sacs in the lungs are damaged. Over time, the inner walls of the
air sacs weaken and rupture-creating larger air spaces instead of
many small ones.
29. Question

Category: Pharmacological and Parenteral Therapies

Marichu was given morphine sulfate for pain. She is sleeping and her respiratory
rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the
following reactions?

• A. Asthma attack

• B. Respiratory arrest

• C. Seizure
 • D. Wake up on her own
Correct Answer: B. Respiratory arrest
Narcotics can cause respiratory arrest if given in large quantities.
• Option A: The client’s respiratory system is most likely being
suppressed, so an acute asthma attack would be unlikely. In an
asthma attack, the airways become swollen and inflamed. The
muscles around the airways contract and the airways produce extra
mucus, causing the breathing (bronchial) tubes to narrow.
• Option C: A seizure is not likely to occur in the situation. Seizures are
mostly caused by paroxysmal discharges from groups of neurons,
which arise as a result of excessive excitation or loss of inhibition.
• Option D: The client’s respiratory rate is too low and she might be
going into a respiratory arrest. Respiratory depression happens when
the lungs fail to exchange carbon dioxide and oxygen efficiently. This
dysfunction leads to a buildup of carbon dioxide in the body, which
can result in health complications.
30. Question

Category: Health Promotion and Maintenance

A 77-year-old male client is admitted for elective knee surgery. Physical
examination reveals shallow respirations but no sign of respiratory distress.
Which of the following is a normal physiologic change related to aging?

• A. Increased elastic recoil of the lungs

• B. Increased number of functional capillaries in the alveoli

• C. Decreased residual volume

• D. Decreased vital capacity

Correct Answer: D. Decreased vital capacity
Reduction in vital capacity is a normal physiologic change including decreased
elastic recoil of the lungs, fewer functional capillaries in the alveoli, and an
increase in residual volume.
• Option A: Elastic recoil in the lungs of the elderly are decreased.
There is homogenous degeneration of the elastic fibers around the
alveolar duct starting around 0 years of age resulting in enlargement
of air spaces.
• Option B: There are fewer functional capillaries in the alveoli as one
ages. The alveoli can lose their shape and become baggy.
• Option C: Decreases in the measures of lung function such as the
vital capacity occurs as part of the age-related changes.