NCLEX Exam Practice Question of the Week - 4/18/12
Question: The nurse is preparing to administer spironolactone (Aldactone) to a client. After assessing the client, what data indicate the need to withhold the medication?
1. Potassium level of 5.8 mEq/L
2. Apical pulse rate of 58 beats/min
3. BP of 130/90 mm Hg
4. Urine output of 30 mL/hr
1. Potassium level of 5.8 mEq/L
2. Apical pulse rate of 58 beats/min
3. BP of 130/90 mm Hg
4. Urine output of 30 mL/hr
Answer: 1
Rationale: Aldactone is a potassium-sparing diuretic. The client’s potassium level is high; therefore the medication should be held, and the doctor should be notified. The other options are not affected by this medication.
NCLEX Exam Practice Question of the Week - 4/25/12
Question: The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention is initiated immediately?
1. Notify the physician.
2. Apply ice to the affected eye.
3. Irrigate the eye with cool water.
4. Accompany the client to the emergency department.
1. Notify the physician.
2. Apply ice to the affected eye.
3. Irrigate the eye with cool water.
4. Accompany the client to the emergency department.
Answer: 2
Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.
Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a physician and receive a thorough eye examination to rule out the presence of other eye injuries.
NCLEX Exam Practice Question of the Week - 5/2/12
Question: A nurse notes that the physician has updated the orders for a client who had a stroke by changing the medication route from parenteral to oral. Before administering the oral medications, it would be most important for the nurse to assess which cranial nerves?
1. Facial and vagus
2. Trigeminal and vagus
3. Trigeminal and hypoglossal
4. Glossopharyngeal and vagus
1. Facial and vagus
2. Trigeminal and vagus
3. Trigeminal and hypoglossal
4. Glossopharyngeal and vagus
Answer: 4
Rationale: Cranial nerves IX (glossopharyngeal) and X (vagus) control swallowing and the gag reflex. The nurse must assess the gag reflex before administering oral medications or feedings, to prevent the risk of aspiration. Cranial nerve VII (facial) (1) controls the motor function of the face and the taste sensation of the anterior 2/3s of the tongue. Cranial nerve V (trigeminal) (2, 3) controls sensation of the forehead, face, nasal cavity, teeth, and eyes as well as the motor function of the muscles used for mastication. Cranial nerve XII (hypoglossal) (3) controls the motor function of the intrinsic and extrinsic muscles of the tongue.
Rationale: Cranial nerves IX (glossopharyngeal) and X (vagus) control swallowing and the gag reflex. The nurse must assess the gag reflex before administering oral medications or feedings, to prevent the risk of aspiration. Cranial nerve VII (facial) (1) controls the motor function of the face and the taste sensation of the anterior 2/3s of the tongue. Cranial nerve V (trigeminal) (2, 3) controls sensation of the forehead, face, nasal cavity, teeth, and eyes as well as the motor function of the muscles used for mastication. Cranial nerve XII (hypoglossal) (3) controls the motor function of the intrinsic and extrinsic muscles of the tongue.
NCLEX Exam Practice Question of the Week - 5/9/12
Question: The nurse provides discharge instructions for a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further instructions? Select all that apply.
1. “If I am ill, I should skip my daily dose.”
2. “If I overeat, I will double my dosage of medication.”
3. “Oral agents are effective in managing Type 2 diabetes.”
4. “If I become pregnant I will discontinue my medication.”
5. “Oral hypoglycemic medications will cause my urine to turn orange.”
6. “My medications are used to manage my diabetes along with diet and exercise.”
1. “If I am ill, I should skip my daily dose.”
2. “If I overeat, I will double my dosage of medication.”
3. “Oral agents are effective in managing Type 2 diabetes.”
4. “If I become pregnant I will discontinue my medication.”
5. “Oral hypoglycemic medications will cause my urine to turn orange.”
6. “My medications are used to manage my diabetes along with diet and exercise.”
Answer: 1, 2, 4, 5
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes. During illness or periods of intense stress, the client should be instructed to monitor his or her blood glucose level frequently and should contact the health care provider if the blood glucose is elevated because insulin may be needed to prevent acute hyperglycemia symptoms. The medication should not be skipped or the dosage should not be doubled. Taking extra pills should be avoided unless specifically prescribed by the health care provider. These medications do not change the color of the urine. Medication should never be discontinued unless instructed to do so by the health care provider. However, the diabetic who becomes pregnant will need to contact her health care provider because the oral diabetic medication may have to be changed to insulin therapy because oral hypoglycemics can be harmful to the fetus.
Priority Nursing Tip: Any changes to prescribed medication usage or amounts should not be made by clients without prior physician approval.
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes. During illness or periods of intense stress, the client should be instructed to monitor his or her blood glucose level frequently and should contact the health care provider if the blood glucose is elevated because insulin may be needed to prevent acute hyperglycemia symptoms. The medication should not be skipped or the dosage should not be doubled. Taking extra pills should be avoided unless specifically prescribed by the health care provider. These medications do not change the color of the urine. Medication should never be discontinued unless instructed to do so by the health care provider. However, the diabetic who becomes pregnant will need to contact her health care provider because the oral diabetic medication may have to be changed to insulin therapy because oral hypoglycemics can be harmful to the fetus.
Priority Nursing Tip: Any changes to prescribed medication usage or amounts should not be made by clients without prior physician approval.
NCLEX Exam Practice Question of the Week - 5/16/12
Question: A client with end-stage renal disease is receiving continuous ambulatory peritoneal dialysis. The nurse is monitoring the client for signs of complications associated with peritoneal dialysis. Select all that apply.
1. Pruritus
2. Oliguria
3. Tachycardia
4. Cloudy outflow
5. Abdominal pain
1. Pruritus
2. Oliguria
3. Tachycardia
4. Cloudy outflow
5. Abdominal pain
Answer: 3, 4, 5
Rationale: Tachycardia can be caused by peritonitis, a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms. Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis.
Rationale: Tachycardia can be caused by peritonitis, a complication of peritoneal dialysis; the heart rate increases to meet the metabolic demands associated with infection. Cloudy or opaque dialysate outflow (effluent) is the earliest sign of peritonitis; it is caused by the constituents associated with an infectious process. Abdominal pain is associated with peritonitis, a complication of peritoneal dialysis; pain results from peritoneal inflammation, abdominal distention, and involuntary muscle spasms. Severe itching (pruritus) is caused by metabolic waste products that are deposited in the skin; dialysis removes metabolic waste products, preventing this adaptation associated with kidney failure. The production of abnormally small amounts of urine (oliguria) is a sign of kidney failure, not a complication of peritoneal dialysis.
NCLEX Exam Practice Question of the Week - 5/23/12
Question: The nurse practitioner orders half-strength enteral formula at a rate of 55 mL/hr. A can holds 250 mL. How many cans would the nurse need for the next 24 hours?
Answer: ________ cans
Answer: ________ cans
Answer: 3 cans
Rationale: 55 mL/hr X 24 hours/day = 1320 total mL for 24 hours or 5.28 cans ÷ 2 (half-strength) = 2.64 cans, or 3 cans.
Rationale: 55 mL/hr X 24 hours/day = 1320 total mL for 24 hours or 5.28 cans ÷ 2 (half-strength) = 2.64 cans, or 3 cans.
NCLEX Exam Practice Question of the Week - 5/30/12
Question: A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply.
1. Place the infant in a private room.
2. Ensure that the infant’s head is in a flexed position.
3. Wear a mask at all times when in contact with the infant.
4. Place the infant in a tent that delivers warm humidified air.
5. Position the infant side-lying, with the head lower than the chest.
6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
1. Place the infant in a private room.
2. Ensure that the infant’s head is in a flexed position.
3. Wear a mask at all times when in contact with the infant.
4. Place the infant in a tent that delivers warm humidified air.
5. Position the infant side-lying, with the head lower than the chest.
6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
Answer: 1, 6
Rationale: Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduce nosocomial transmission of RSV. A mask is unnecessary. Additionally, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
Rationale: Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduce nosocomial transmission of RSV. A mask is unnecessary. Additionally, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
Exam Practice Question of the Week - 6/6/12
Question: Which of the following laboratory results on a newly admitted client should the nurse report to the physician immediately?
1. Potassium 4.1 mEq/L
2. Hemoglobin 12.2 g/dL
3. Platelet count 165,000 mm3
4. White blood cell count 17,200 mm3
1. Potassium 4.1 mEq/L
2. Hemoglobin 12.2 g/dL
3. Platelet count 165,000 mm3
4. White blood cell count 17,200 mm3
Answer: 4
Rationale: A white blood cell (WBC) count of 17,200 mm3 would be highest priority because the count is elevated and may indicate an acute infection. Normal WBC results are 4300 to 10,800 mm3. The other results are within normal limits: potassium 3.5 to 5.0 mEq/L (1); hemoglobin 13.5 to 18 g/dl (male) or 12 to 16 g/dL (female) (2); platelets 150,000 to 450,000 mm3 (3).
Rationale: A white blood cell (WBC) count of 17,200 mm3 would be highest priority because the count is elevated and may indicate an acute infection. Normal WBC results are 4300 to 10,800 mm3. The other results are within normal limits: potassium 3.5 to 5.0 mEq/L (1); hemoglobin 13.5 to 18 g/dl (male) or 12 to 16 g/dL (female) (2); platelets 150,000 to 450,000 mm3 (3).
NCLEX Exam Practice Question of the Week - 6/13/12
Question:A client with heart failure was experiencing difficulty breathing and increased pulmonary congestion. The physician prescribed furosemide (Lasix) 40 mg to be given intravenously and it was given an hour ago by the nurse. Which indicates the therapy has been effective?
1. The lungs are now clear to auscultation
2. The urine output has increased by 400 mL
3. The serum potassium has decreased from 4.7 mEq to 4.1 mEq
4. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg
1. The lungs are now clear to auscultation
2. The urine output has increased by 400 mL
3. The serum potassium has decreased from 4.7 mEq to 4.1 mEq
4. The blood pressure has decreased from 118/64 mm Hg to 106/62 mm Hg
Answer: 1
Rationale: Furosemide (Lasix) is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason the furosemide was administered.
Priority Nursing Tip: When administering a medication, knowing its purpose will assist in evaluating its effectiveness.
Rationale: Furosemide (Lasix) is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason the furosemide was administered.
Priority Nursing Tip: When administering a medication, knowing its purpose will assist in evaluating its effectiveness.
NCLEX Exam Practice Question of the Week - 6/20/12
Question: A client is admitted with 50% of the body surface area burned after an industrial explosion and fire. The client’s serum albumin is 1.5 g/dL, the hematocrit is 30%, the urine specific gravity is 1.025, and the serum globulin is 3 g/dL. When evaluating the client’s response to fluid replace¬ment, the nurse should prepare to administer a colloid when the:
1. Globulin is 3 g/dL
2. Albumin is below 2 g/dL
3. Hematocrit is below 32%
4. Urine specific gravity is 1.018
1. Globulin is 3 g/dL
2. Albumin is below 2 g/dL
3. Hematocrit is below 32%
4. Urine specific gravity is 1.018
Answer: 2
Rationale: Administration of a colloid is indicated when the serum albumin decreases below 2 g/dL; then, albumin must be administered to increase the level to the expected range of 3.5 to 5.5 g/dL; this increases the oncotic pressure and prevents the shift of fluid out of the intravascular compartment. A globulin of 3 g/dL is within the expected parameters of 2.3 to 3.4 g/dL. A hematocrit level of 32% is low and indicates overhydration; administration of a colloid will increase this problem. Urine specific gravity is within the expected limits of 1.010 to 1.030.
Rationale: Administration of a colloid is indicated when the serum albumin decreases below 2 g/dL; then, albumin must be administered to increase the level to the expected range of 3.5 to 5.5 g/dL; this increases the oncotic pressure and prevents the shift of fluid out of the intravascular compartment. A globulin of 3 g/dL is within the expected parameters of 2.3 to 3.4 g/dL. A hematocrit level of 32% is low and indicates overhydration; administration of a colloid will increase this problem. Urine specific gravity is within the expected limits of 1.010 to 1.030.
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