Question 1

A client with lung cancer has a lobectomy of the left lung and is returned to the recovery room with a chest tube connected to a closed, underwater-seal drainage system. The nurse observes that the system is functioning correctly when he or she notes that the pressure in the suction control chamber of the systems remains at ________________pressure.

Accepted Answer

The answer of A client with lung cancer has a...

Question 2

Which statement by a nurse working with a client who is suffering from paranoid delusions and who is not very talkative would block therapeutic communication?
A)"You seem to be more suspicious of the other clients today."
B)"I feel you have made progress by speaking about your fears."
C)"I know just how you feel.I often see the head nurse waiting for me to make a mistake."
D)"You mentioned that you see them looking through the window.Please tell me more about that."

Accepted Answer

This statement is inappropriate because it is not an accurate reflection of the client's experience and implies that the nurse shares the same type of delusion as the client, which can be damaging to the therapeutic relationship.

Answer: B or D
 Both statements encourage further communication and exploration of the client's experiences and feelings, which is the goal of therapeutic communication. Option B validates the client's progress and encourages them to continue sharing their fears, while option D shows interest and encourages the client to provide more detail about their delusions.

Question 3

Select the nursing action that would best help reduce the cramping experience by a client who was receiving intermittent feedings though a gastric tube (PEG tube). A)Warm the feeding to near body temperature prior to administration. B)Elevate the client's head to 35 to 45 degreesduring feedings. C)Encourage the client to suck on a hard candy 5 to 10 minutes prior to the feeding. D)Assess the tube for placement prior to each feeding.

Accepted Answer

Warming the feeding to near body temperature prior to administration can help reduce cramping by preventing the stomach from contracting in response to a sudden influx of cold liquid.

Question 4

A client is being treated for depression with phenelzine (Nardil). Which statement by the client indicates that the goal for the client to understand the potential side effects of the antidepressant has been achieved?
A)"I should wear sturdy and supportive shoes when I'm outside."
B)"My legs should be elevated when I'm sitting."
C)"I must avoid eating at Chinese restaurants."
D)"Colognes and perfumed soaps can cause allergic reactions."

Accepted Answer

Phenelzine is a monoamine oxidase inhibitor (MAOI), which can interact with certain foods that contain high levels of tyramine, such as Chinese food, aged cheese, and cured meats. This interaction can cause a dangerous and potentially fatal hypertensive crisis. Therefore, avoiding foods with high levels of tyramine is a crucial aspect of client education for phenelzine. Choices A, B, and D are not related to the potential side effects of phenelzine.

Question 5

A client with colon cancer has surgery with a colostomy. Which assessments indicate to the nurse that the client is developing postoperative complications? (Select all that apply.)
A) Urine output > 30 mL/hr
B) Dusky appearance of the stoma
C) Stoma protrusion from the skin
D) Small amount of blood-tinged liquid stool in colostomy bag
E) Edema of the stoma during the first 24 hours post-operation
F) Sharp abdominal pain

Accepted Answer

- A dusky appearance of the stoma indicates poor blood flow, which could be a sign of necrosis.- Stoma protrusion (prolapse) from the skin is abnormal and indicates a complication.- Sharp abdominal pain could indicate an infection or other serious postoperative complications.

Question 6

An adult client with Hodgkin's disease who weighs 168 pounds is to receive vincristine (Oncovin), 25 mcg/kg IV. Calculate the correct medication dosage and type the answer in the box.

Accepted Answer

The answer of An adult client with Hodgkin's disease who...

Question 7

A client with severe anxiety is being treated with lorazepam (Ativan) and outpatient therapy. Which statement indicates that the client requires additional discharge instructions for this medication?
A)"If I become drowsy or have blurred vision, I need to stop the medication immediately."
B)"This medication can be habit forming, so I should take it only as directed."
C)"I need to add foods such as fresh fruits and grain to my diet."
D)"If I get a cold I should check with my primary health-care provider before taking cold medicines."

Accepted Answer

Lorazepam (Ativan) can cause drowsiness and blurred vision as side effects, but patients should not stop the medication immediately without consulting their healthcare provider. This statement indicates a misunderstanding of how to manage side effects and the need for further instruction.

Question 8

Identify the statement made by a psychiatric clinical nurse specialist to a client with anorexia nervosa that best demonstrates the use of cognitive therapy.
A)"You seem to feel much better about yourself when you eat something."
B)"Being thin doesn't seem to solve your problems, since you're thin now and still unhappy."
C)"It must be difficult to talk about private matters with someone you just met."
D)"What are your feelings about not eating the food that you prepare?"

Accepted Answer

This statement challenges the client's belief that being thin will solve all their problems and helps the client to see that their happiness is not solely dependent on their weight. This is a key aspect of cognitive therapy, which aims to challenge and modify negative thought patterns.

Question 9

Hospice care is often used for the treatment of terminally ill clients with cancer. Identify the basic characteristics found in hospice programs. (Select all that apply.)
A) Control of client symptoms and relief of pain
B) Treatment of the client as a separate entity from the family to reduce grief
C) Services provided on the ability to pay
D) Use of trained volunteers to augment staff services
E) Bereavement follow-up
F) Care provided in the home independent of physicians

Accepted Answer

Hospice care focuses on the comfort and quality of life for terminally ill patients, often involving symptom and pain management (A), the use of trained volunteers to support staff and patients (D), and bereavement follow-up for families after the patient's death (E).

Question 10

A client who had a kidney transplant experiences myelosuppression as one of the side effects of the antirejection medication. Select the points the nurse should include in the client's home discharge plan. (Select all that apply.)
A) Avoid people who have recently received attenuated vaccines.
B) Use ibuprofen (Motrin) or acetaminophen (Tylenol) every 4 hours for pain.
C) Wash your hands frequently.
D) Clean the cat-litter box daily.
E) Avoid going to the shopping mall.
F) Gargle with a mouthwash for a sore throat because it is an expected side effect.

Accepted Answer

- A) Avoiding people who have recently received live attenuated vaccines is important because the client's suppressed immune system increases their risk of contracting infections.- C) Frequent hand washing is a key infection prevention measure, especially important for someone with a compromised immune system.- E) Avoiding crowded places like shopping malls reduces the risk of exposure to infectious agents.

Question 11

The nurse notes that the primary health-care provider has prescribed that the total parenteral nutrition (TPN) a client has been receiving for the past 10 days be discontinued and changed to 0.9% normal saline. Which action would be most appropriate for the nurse to take?
A)Stop the TPN and change the solution to 0.9% normal saline as soon as it is available.
B)Allow the remaining TPN to infuse until the bag is empty and then change the solution to 0.9% normal saline.
C)Gradually reduce the rate of the TPN over the next 4 to 6 hours and then change the solution to 0.9% normal saline.
D)Question the primary health-care provider about the change because the solution is inappropriate.

Accepted Answer

Abruptly stopping TPN can cause electrolyte imbalances and hypoglycemia. Gradually reducing the rate of TPN over the next 4 to 6 hours will allow for a smoother transition to 0.9% normal saline. Nursing best practice is to always question an order that appears inappropriate or unclear, but in this scenario, the order seems appropriate. Therefore, choice D is not the best option. Options A and B may cause complications and are not the best choices.

Question 12

Identify the primary complications for which the nurse should monitor clients who have had a subtotal thyroidectomy for treatment of hyperthyroidism. (Select all that apply.)
A) Vomiting
B) Airway obstruction
C) Thrombocytopenia
D) Hidden bleeding
E) Hypothyroidism
F) Hypocalcemia

Accepted Answer

- Airway obstruction is a potential complication due to swelling and bleeding in the neck area.
- Hidden bleeding can occur within the first 24-48 hours after surgery, and it is important to monitor for signs of bleeding such as swelling, tenderness, or difficulty swallowing.
- Hypothyroidism can occur when a large portion of the thyroid gland is removed, and the nurse should monitor for signs of hormonal imbalances such as fatigue, weight gain, and cold intolerance.
- Hypocalcemia is a risk when there is damage to the parathyroid glands during surgery, which can lead to a decrease in calcium levels. The nurse should monitor for signs of hypocalcemia such as muscle twitching, numbness, and tingling. 
Vomiting and thrombocytopenia are not primary complications associated with subtotal thyroidectomy for hyperthyroidism.

Question 13

A client receiving total parenteral nutrition (TPN) through a central line reports chest discomfort and mild dyspnea. The nurse notes a churning sound over the permanent pacemaker implantation (PMI) and tachycardia. Which action should the nurse take first?
A)Replace the tubing and the TPN solution immediately.
B)Clamp the central catheter and place the client on the left side with the head lower than the body.
C)Start oxygen by mask to reduce the hypoxia and notify the primary health-care provider immediately.
D)Assess the client for cough and cyanosis while evaluating the central catheter site for signs of infection.

Accepted Answer

Clamping the central catheter and positioning the client on the left side with the head lower than the body (Trendelenburg position) is the first action the nurse should take in response to symptoms that suggest an air embolism, a potential complication of central line use. This position helps to trap air in the apex of the right atrium, reducing the risk of it moving to the lungs and causing more severe complications.

Question 14

Which nursing action is most important in the care of a client who is receiving 300 mL of Isocal by nasogastric feeding tube every 4 hours?
A)Keep the head of the bed elevated 35 to 45 degrees at all times.
B)Check the tube for placement prior to each feeding.
C)Obtain daily weights and accurate I&O to monitor status.
D)Monitor the client for dumping syndrome.

Accepted Answer

Checking the placement of the nasogastric tube prior to each feeding is the most important nursing action because incorrect placement can result in aspiration, which can be life-threatening. While keeping the head of the bed elevated and monitoring for dumping syndrome are important actions, they are not as crucial as ensuring proper tube placement. Obtaining daily weights and I&O is important for monitoring fluid balance, but it is not directly related to the administration of Isocal through a nasogastric tube.

Question 15

Identify the assessment found by a nurse on a client who is admitted with a possible accidental overdose of imipramine (Tofranil) that would require the most immediate intervention.
A)Depressed deep tendon reflexes and Glasgow Coma Scale of 11
B)Sinus tachycardia of 128 with a QRS complex of 0.14 second
C)Ecchymotic areas on arms and an HCT of 33%
D)Distended abdomen and decreased bowel sounds

Accepted Answer

Sinus tachycardia with a prolonged QRS complex is a sign of imipramine toxicity and requires immediate intervention. This could progress to ventricular dysrhythmias, seizures, and cardiac arrest if not treated promptly. The other options may also require intervention but are not as immediately life-threatening as the cardiac manifestation.

Question 16

During a prenatal visit, the nurse is teaching a pregnant client about sources of complete protein. Identify the food with the highest amount of this nutrient.
A)Two boiled eggs
B)1 cup whole-grain cereal
C)1 cup red beans
D)One fried chicken leg

Accepted Answer

Two boiled eggs provide a high amount of complete protein, containing all essential amino acids necessary for the body.

Question 17

A 1-day-postoperative client has both morphine sulfate (MS) and meperidine (Demerol) prescribed for pain. Upon which assessment would the nurse decide to give the meperidine rather than the morphine sulfate?
A)Pain has increased from a 2/10 to a 6/10
B)B/P 110/58, pulse 62 BPM
C)Temperature 99.2°F, respirations 10/min
D)Awake, alert, and oriented - 3

Accepted Answer

Meperidine is preferred over morphine in cases where respiratory depression is a concern, as indicated by a low respiratory rate (respirations 10/min).

Question 18

Identify the proper sequence for the steps the nurse should follow in changing the dressing on an incision that is closed with surgical staples.
____ Apply antiseptic ointment to the suture line.
____ Cleanse the area around the incision with an appropriate cleansing solution.
____ Explain the procedure to the client.
____ Teach the client how to minimize stress on the incision line.
____ Note characteristics of any drainage.
____ Remove the old dressing using clean technique.
____ Apply the new dressing using sterile technique.

Accepted Answer

The answer of Identify the proper sequence for the steps...

Question 19

A client who is to receive external radiation therapy asks the nurse why the cancer cells in his body are so harmful. The nurse responds that a characteristic found in all cancer cells, called ____________________, allows the cells to reproduce in a different manner that is harmful to the healthy body tissues.

Accepted Answer

The answer of A client who is to receive external...

Question 20

A client is to receive a heparin drip at 800 units per hour. The medication is mixed heparin 20,000 units in 500 mL of D5W. At what rate should the nurse set the volumetric pump?

Accepted Answer

The answer of A client is to receive a heparin...

Quiz 11: Nclex: What You Need to Know

Which statement by a nurse working with a client who is suffering from paranoid delusions and who is not very talkative would block therapeutic communication?

Select the nursing action that would best help reduce the cramping experience by a client who was receiving intermittent feedings though a gastric tube (PEG tube) .

A client is being treated for depression with phenelzine (Nardil) . Which statement by the client indicates that the goal for the client to understand the potential side effects of the antidepressant has been achieved?

A client with colon cancer has surgery with a colostomy. Which assessments indicate to the nurse that the client is developing postoperative complications? (Select all that apply.)

An adult client with Hodgkin's disease who weighs 168 pounds is to receive vincristine (Oncovin), 25 mcg/kg IV. Calculate the correct medication dosage and type the answer in the box.

A client with severe anxiety is being treated with lorazepam (Ativan) and outpatient therapy. Which statement indicates that the client requires additional discharge instructions for this medication?

Identify the statement made by a psychiatric clinical nurse specialist to a client with anorexia nervosa that best demonstrates the use of cognitive therapy.

Hospice care is often used for the treatment of terminally ill clients with cancer. Identify the basic characteristics found in hospice programs. (Select all that apply.)

A client who had a kidney transplant experiences myelosuppression as one of the side effects of the antirejection medication. Select the points the nurse should include in the client's home discharge plan. (Select all that apply.)

The nurse notes that the primary health-care provider has prescribed that the total parenteral nutrition (TPN) a client has been receiving for the past 10 days be discontinued and changed to 0.9% normal saline. Which action would be most appropriate for the nurse to take?

Identify the primary complications for which the nurse should monitor clients who have had a subtotal thyroidectomy for treatment of hyperthyroidism. (Select all that apply.)

A client receiving total parenteral nutrition (TPN) through a central line reports chest discomfort and mild dyspnea. The nurse notes a churning sound over the permanent pacemaker implantation (PMI) and tachycardia. Which action should the nurse take first?

Which nursing action is most important in the care of a client who is receiving 300 mL of Isocal by nasogastric feeding tube every 4 hours?

Identify the assessment found by a nurse on a client who is admitted with a possible accidental overdose of imipramine (Tofranil) that would require the most immediate intervention.

During a prenatal visit, the nurse is teaching a pregnant client about sources of complete protein. Identify the food with the highest amount of this nutrient.

A 1-day-postoperative client has both morphine sulfate (MS) and meperidine (Demerol) prescribed for pain. Upon which assessment would the nurse decide to give the meperidine rather than the morphine sulfate?

A client is to receive a heparin drip at 800 units per hour. The medication is mixed heparin 20,000 units in 500 mL of D5W. At what rate should the nurse set the volumetric pump?