nursing nclex quiz answer and rationale part II


Topics or concepts included in this exam are diseases common to children, lithium therapy,diabetes,pediatric nursing and in general.


1. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the
A. Surgical repair of a diseased coronary artery
B. Placement of an automatic internal cardiac defibrillator
C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
D. Non-invasive radiographic examination of the heart

2. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize
A. They can expect the child will be mentally retarded
B. Administration of thyroid hormone will prevent problems
C. This rare problem is always hereditary
D. Physical growth/development will be delayed

3. A priority goal of involuntary hospitalization of the severely mentally ill client is
A. Re-orientation to reality
B. Elimination of symptoms
C. Protection from harm to self or others
D. Return to independent functioning

4. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “suppression”?
A. “I don’t remember anything about what happened to me.”
B. “I’d rather not talk about it right now.”
C. “It’s the other entire guy’s fault! He was going too fast.”
D. “My mother is heartbroken about this.”

5. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?
A. Altered tissue perfusion
B. Risk for fluid volume deficit
C. High risk for hemorrhage
D. Risk for infection

6. A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
A. Expose the cast to air and turn the child frequently
B. Use a heat lamp to reduce the drying time
C. Handle the cast with the abductor bar
D. Turn the child as little as possible

7. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A. Instruct the client to maintain a regular diet the day prior to the examination
B. Restrict the client’s fluid intake 4 hours prior to the examination
C. Administer a laxative to the client the evening before the examination
D. Inform the client that only 1 x-ray of his abdomen is necessary

8. Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parent’s remark: “We just don’t know how he caught the disease!” The nurse’s response is based on an understanding that
A. AGN is a streptococcal infection that involves the kidney tubules
B. The disease is easily transmissible in schools and camps
C. The illness is usually associated with chronic respiratory infections
D. It is not “caught” but is a response to a previous B-hemolytic strep infection

9. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3-day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the healthcare provider immediately?
A. 3 episodes of vomiting in 1 hour
B. Periodic crying and irritability
C. Vigorous sucking on a pacifier
D. No measurable voiding in 4 hours

10. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?
A. Check vital signs
B. Massage the fundus
C. Offer a bedpan
D. Check for perineal lacerations

11. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A. Unequal leg length
B. Limited adduction
C. Diminished femoral pulses
D. Symmetrical gluteal folds

12. To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would
A. Assist the client to use the bedside commode
B. Administer stool softeners every day as ordered
C. Administer antidysrhythmics prn as ordered
D. Maintain the client on strict bed rest

13. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to
A. Give the client orientation materials and review the unit rules and regulations
B. Introduce him/her and accompany the client to the client’s room
C. Take the client to the day room and introduce her to the other clients
D. Ask the nursing assistant to get the client’s vital signs and complete the admission search

14. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?

A. “I have constant blurred vision.”
B. “I can’t see on my left side.”
C. “I have to turn my head to see my room.”
D. “I have specks floating in my eyes.”

15. A client with asthma has low pitched wheezes present in the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
A. Has increased airway obstruction
B. Has improved airway obstruction
C. Needs to be suctioned
D. Exhibits hyperventilation

16. Which behavioral characteristic describes the domestic abuser?
A. Alcoholic
B. Overconfident
C. High tolerance for frustrations
D. Low self-esteem

17. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend
A. Isometric
B. Range of motion
C. Aerobic
D. Isotonic

18. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of the following nursing interventions is a priority?
A. Counsel the woman to consent to HIV screening
B. Perform tests for sexually transmitted diseases
C. Discuss her high risk for cervical cancer
D. Refer the client to a family planning clinic

19. A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
A. Arrange to change client care assignments
B. Explain that this behavior is expected
C. Discuss the appropriate use of “time-out”
D. Explain that the child needs extra attention

20. While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
A. Strange bed and surroundings
B. Separation from parents
C. Presence of other toddlers
D. Unfamiliar toys and games

21. While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?
A. They are able to make simple association of ideas
B. They are able to think logically in organizing facts
C. Interpretation of events originate from their own perspective
D. Conclusions are based on previous experiences

22. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
A. Nutrition
B. Elimination
C. Activity
D. Safety

23. Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
A. Sports and games with rules
B. Finger paints and water play
C. “Dress-up” clothes and props
D. Chess and television programs

24. A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
A. High Fowler’s
B. Supine
C. Left lateral
D. Low Fowler’s

25. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A. Urinary output of 30 ml per hour
B. No complaints of thirst
C. Increased hematocrit
D. Good skin turgor around burn

Answers & Rationale
.
1. Answer: C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
Option C: PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization. Aorta coronary bypass Graft is the surgical procedure to repair a diseased coronary artery.

2. Answer: B. Administration of thyroid hormone will prevent problems
Option B. Early identification and continued treatment with hormone replacement correct this condition.

3. Answer: C. Protection from self-harm and harm to others
Option C: Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.

4. Answer: A. “I don”t remember anything about what happened to me.”

Option A: Suppression is willfully putting an unacceptable thought or feeling out of one’s mind. A deliberate exclusion “voluntary forgetting” is generally used to protect one’s own self-esteem.
5. Answer: D. Risk for infection

Option D: Membranes ruptured over 24 hours prior to birth greatly increases the risk of infection to both mother and the newborn.

6. Answer: A. Expose the cast to air and turn the child frequently
Option A: The child should be turned every 2 hours, with surface exposed to the air.

7. Answer: C. Administer a laxative to the client the evening before the examination
Option C: Bowel prep is important because it will allow greater visualization of the bladder and ureters.

8. Answer: D. It is not “caught” but is a response to a previous B-hemolytic strep infection
Option D: AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior and is considered as a noninfectious renal disease.

9. Answer: D. No measurable voiding in 4 hours
Option D: The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.

10. Answer: B. Massage the fundus

Option B: The nurse’s first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery.
11. Answer: A. Unequal leg length
Option A: Shortening of a leg is a sign of developmental dysplasia of the hip.

12. Answer: B. Administer stool softeners every day as ordered
Option B: Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the Valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.

13. Answer: B. Introduce him/herself and accompany the client to the client’s room
Option B: Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.

14. Answer: C. “I have to turn my head to see my room.”
Option C: Intraocular pressure becomes elevated which slowly produces a progressive loss of the peripheral visual field in the affected eye along with rainbow halos around lights. Intraocular pressure becomes elevated from the microscopic obstruction of the trabecular meshwork. If left untreated or undetected blindness results in the affected eye.

15. Answer: A. Has increased airway obstruction
Option A: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions no support exists to indicate the need for suctioning.

16. Answer: D. Low self-esteem
Option D: Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have a low self-esteem, and have a great need to exercise control or power-over partner.

17. Answer: A. Isometric
Option A: The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.

18. Answer: A. Counsel the woman to consent to HIV screening
Option A: The client”s behavior places her at high risk for HIV. Testing is the first step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.

19. Answer: B. Explain that this behavior is expected
Option B: During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.

20. Answer: B. Separation from parents
Option B: Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.

21. Answer: B. Think logically in organizing facts
Option B: The child in the concrete operations stage, according to Piaget, is capable of mature thought when allowed to manipulate and organize objects.
22. Answer: D. Safety

Option D: Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan.
23. Answer: A. Sports and games with rules

Option A: The purpose of play for the 7-year-old is cooperation. Rules are very important. Logical reasoning and social skills are developed through play.

24. Answer: A. High Fowler”s
Option A: Sitting in a chair or resting in a bed in high Fowler”s position decreases the cardiac workload and facilitates breathing.
25. Answer: A. Urinary output of 30 ml per hour
Option A: For a child of this age, this is adequate output, yet does not suggest overload.

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