Answer Key NCLEX PRACTICE TEST 102

1. 
   

2. Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making answer C incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making answer D incorrect.

3. Answer B is correct. Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Answer A is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position, as stated in answer C. Answer D is incorrect because the medication does not have to be covered with foil.

4. Answer C is correct. A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers A, B, and D are incorrect.

5. Answer C is correct. Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers A and B are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, as stated in answer D.

6. Answer C is correct. Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client; thus, answers A, B, and D are incorrect. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.

7. Answer B is correct. The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, answers A, C, and D are incorrect.

8. Answer A is correct. The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line, so answer B is incorrect. Erb’s point is the point at which you can hear the valves close simultaneously, making answer C incorrect. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer; thus, answer D is incorrect.

9. Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Answers A, C, and D are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.

10. Answer B is correct. The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Answer A is incorrect because weighing the client will not indicate peripheral edema. Answer C is incorrect because checking the intake and output will not indicate peripheral edema. Answer D is incorrect because checking for pitting edema is less reliable than measuring with a paper tape measure.

11. Answer D is correct. Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect.

12. Answer B is correct. The client with a facial stroke will have difficulty swallowing and chewing, and the foods in answer B provide the least amount of chewing. The foods in answers A, C, and D would require more chewing and, thus, are incorrect.

13. Answer A is correct. Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer B does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer C. Answer D is incorrect because there is no need to save the dessert until bedtime.

14. Answer B is correct. The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although answers A, C, and D might be important, they are not the primary answer to the question.

15. Answer D is correct. Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Answers A, B, and C are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.

16. Answer A is correct. The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Answers B, C, and D are incorrect because these vaccines are given later in life.

17. Answer B is correct. Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so answer A is incorrect. Tagamet can be taken in a single dose at bedtime, making answer C incorrect. Answer D does not treat the problem adequately and, therefore, is incorrect.

18. Answer A is correct. If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Answer B is incorrect because simply telling the client to calm down will not work. Answer C is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Answer D is incorrect because if the client is left alone he might harm himself.

19. Answer A is correct. If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. The answers in B, C, and D are actions that relate to postpartal hemorrhage.

20. Answer C is correct. A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in A had said pneumocystis pneumonia, answer A would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Answers B and D are not directly related to the stem.

21. Answer B is correct. If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches making answers A, C, and D incorrect.

22. Answer A is correct. Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so answer B is incorrect. Answers C and D might be present but are not related to Kernig’s sign.

23. Answer B is correct. Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand so answers A, C, and D are incorrect.

24. Answer C is correct. Increased confusion at night is known as "sundowning" syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Answer A is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, answer B is incorrect. A delusion is a firm, fixed belief; therefore, answer D is incorrect.

25. Answer C is correct. The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Answers A and D are incorrect because the nurse is dismissing the client. Answer B is validating the delusion.

26. Answer D is correct. Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, answers A, B, and C are incorrect.

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call nursing office for details

San Juan de Dios Hospital

bring PRC ID


Martinez Memorial Hospital - Caloocan

NCLEX MANILA TAKERS REMINDER

For those who are scheduled to take their NCLEX in Trident here in Manila, I would like to share with you some reminders based on what I experienced.

1. schedule – come early. my schedule is 9am, I arrived at 7am, sobrang aga, sarado pa ang Trident, di pa nagpapapasok, kaya tambay lang muna sa labas, or sa McDo sa likod. 8am nag start nagpapasok ang Trident guard. i have no idea kung ano naman ang situation sa 3pm schedule.

2. companions – there is no waiting area, bawal pumasok ang companions sa loob ng building, karamihan ay nasa labas lang naghihintay. or tell your companions to go somewhere else and i-text nyo na lang sila para sunduin ka kapag tapos na ang exam mo.

3. food – hindi din allowed ang baon. yung iba may dalang bottled water, umiinom habang naghihintay sa line. make sure you have eaten before taking your exam, because you would not know what time your exam would end.

4. clothing - wear anything decent and comfortable. pwede mag jeans, shirt, rubber shoes, sandals, flip-flops. kung lamigin ka, mag long sleeves na lang, kasi minsan hindi allowed ang jacket sa loob ng testing center, pinapaiwan sa locker. para sa akin, tolerable naman ang temperature sa loob.

5. review materials - pwede naman magdala ng books para makapagbasa habang naghihintay sa line. pero i suggest na dalhin na lang ang mga maliliit na notes, kasi dagdag pa sa anxiety level ang last-minute review.

idagdag ko lang... ang mga dapat dalhin…

1. confirmation letter – hinahanap ito ng guard sa main entrance ng building, para i-check nya kung tama ang date and time sched mo. di nya kukunin yan, babasahin lang nya.

2. an extra ID – can be a school ID, review center ID, SSS ID, PRC ID, etc, hahanapin din ng guard sa main entrance ng building in exchange of a visitor's ID.

3. downloaded ATT – must be downloaded from your email and printed sa computer printer. di pwede ang xeroxed ATT or yung mukhang pina-xerox na ATT. mas okay kung colored ang pagkakaprint para talagang original.

4. original yellow ATT – just in case hindi tanggapin ang printed ATT mo (dahil malabo ang pagka-print, or mukhang xerox ang pagka-print, o kung sa anupamang dahilan). yung iba ay pinapalabas pa nila ng building para maghanap ng internet cafe para mag download at mag print ulit ng ATT. hassle yun di ba? dagdag pa sa anxiety level. ibabalik din naman sa applicant ang ATT after the Pearson security check. isulat na pala ang exam date and place sa designated blanks sa likod ng ATT, although you will be given time to fill that up.

5. updated passport – ayaw ng Pearson na naka-plastic cover ang passport at madaming nakaipit, ipapatanggal sa iyo yan. pls note also about the name extensions such as Jr, Sr, III, IV. yung iba kasi hindi nagtutugma (kunwari sa Jr., nakasulat sa passport as part of the given name, pero sa ATT naman ay part of the surname). i dont know what happened to the test-taker na may ganyang kaso.

common sources of problems:
1. ATT - malabo print, mukhang xerox, kulang ang pages
2. passport - no signature (i have no idea about the new machine-readable passport)
3. name mismatch - name must be matched in both the ATT and passport (given name, middle name, surname)

so far, yun lang naman ang basic requirements...
and pray silently while waiting in line for your turn...

good luck and God bless…

-courtesy of nelle

NLE REVIEW GUIDE

NLE Practice questions with rationale:
http://www.sendspace.com/file/loj2ed

pls download winrar to open up docs.

NRES NOTES:
http://file2upload.net/download/21028/INTRODUCTION_20TO_20NURSING_20RESEARCH.pdf.html

MATERNITY NURSING
http://www.savefile.com/files/1110911

PEDIA
http://savefile.com/files/1110916

PSYCH
http://savefile.com/files/1110917

PALMR
http://savefile.com/files/1110919

NCLEX Practice Test 103

4. 
   

1. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

1. Document the finding

2. Report the finding to the doctor

3. Prepare the client for a C-section

4. Continue primary care as prescribed

2. A client with a diagnosis of HPV is at risk for which of the following?

1. Hodgkin's lymphoma

2. Cervical cancer

3. Multiple myeloma

4. Ovarian cancer

3. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

1. Syphilis

2. Herpes

3. Gonorrhea

4. Condylomata

4. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

1. Venereal Disease Research Lab (VDRL)

2. Rapid plasma reagin (RPR)

3. Florescent treponemal antibody (FTA)

4. Thayer-Martin culture (TMC)

5. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

1. Elevated blood glucose

2. Elevated platelet count

3. Elevated creatinine clearance

4. Elevated hepatic enzymes

6. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

1. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

2. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.

3. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

4. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

7. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?

1. Magnesium sulfate 4gm (25%) IV

2. Brethine 10mcg IV

3. Stadol 1mg IV push every 4 hours as needed prn for pain

4. Ancef 2gm IVPB every 6 hours

8. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

1. The infant is at low risk for congenital anomalies.

2. The infant is at high risk for intrauterine growth retardation.

3. The infant is at high risk for respiratory distress syndrome.

4. The infant is at high risk for birth trauma.

9. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

1. Crying

2. Wakefulness

3. Jitteriness

4. Yawning

10. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

1. Decreased urinary output

2. Hypersomnolence

3. Absence of knee jerk reflex

4. Decreased respiratory rate

11. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

1. Place her in Trendelenburg position

2. Decrease the rate of IV infusion

3. Administer oxygen per nasal cannula

4. Increase the rate of the IV infusion

12. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

1. Alteration in nutrition

2. Alteration in bowel elimination

3. Alteration in skin integrity

4. Ineffective individual coping

13. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

1. Inspection of the abdomen for enlargement

2. Bimanual palpation for hepatomegaly

3. Daily measurement of abdominal girth

4. Assessment for a fluid wave

14. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

1. Alteration in cerebral tissue perfusion

2. Fluid volume deficit

3. Ineffective airway clearance

4. Alteration in sensory perception

15. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

1. Likes to play football

2. Drinks several carbonated drinks per day

3. Has two sisters with sickle cell tract

4. Is taking acetaminophen to control pain

16. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

1. Allow the client to keep the fruit

2. Place the fruit next to the bed for easy access by the client

3. Offer to wash the fruit for the client

4. Tell the family members to take the fruit home

17. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:

1. Place the client in Trendelenburg position

2. Increase the infusion of Dextrose in normal saline

3. Administer atropine intravenously

4. Move the emergency cart to the bedside

18. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

1. Order a chest x-ray

2. Reinsert the tube

3. Cover the insertion site with a Vaseline gauze

4. Call the doctor

19. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

1. Assess for signs of abnormal bleeding

2. Anticipate an increase in the Coumadin dosage

3. Instruct the client regarding the drug therapy

4. Increase the frequency of neurological assessments

20. Which selection would provide the most calcium for the client who is 4 months pregnant?

1. A granola bar

2. A bran muffin

3. A cup of yogurt

4. A glass of fruit juice

21. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?

1. The nurse places a sign over the bed not to check blood pressure in the right arm.

2. The nurse places a padded tongue blade at the bedside.

3. The nurse inserts a Foley catheter.

4. The nurse darkens the room.

22. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?

1. Ask the mother to leave while the blood transfusion is in progress

2. Encourage the mother to reconsider

3. Explain the consequences without treatment

4. Notify the physician of the mother's refusal

23. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

1. Hypovolemia

2. Laryngeal edema

3. Hypernatremia

4. Hyperkalemia

24. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?

1. The client selects a balanced diet from the menu.

2. The client's hemoglobin and hematocrit improve.

3. The client's tissue turgor improves.

4. The client gains weight.

25. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

1. Pain beneath the cast

2. Warm toes

3. Pedal pulses weak and rapid

4. Paresthesia of the toes

NCLEX Practice Test 102

26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

1. Report muscle weakness to the physician.
2. Allow six months for the drug to take effect.
3. Take the medication with fruit juice.
4. Ask the doctor to perform a complete blood count before starting the medication

27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

1. Utilize an infusion pump
2. Check the blood glucose level
3. Place the client in Trendelenburg position
4. Cover the solution with foil

28. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

1. Blood pressure of 126/80
2. Blood glucose of 110mg/dL
3. Heart rate of 60bpm
4. Respiratory rate of 30 per minute

29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

1. Replenish his supply every 3 months
2. Take one every 15 minutes if pain occurs
3. Leave the medication in the brown bottle
4. Crush the medication and take with water

30.The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

1. Macaroni and cheese
2. Shrimp with rice
3. Turkey breast
4. Spaghetti

31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

1. Feet
2. Neck
3. Hands
4. Sacrum

32. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

1. Phlebostatic axis
2. PMI
3. Erb's point
4. Tail of Spence

33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

1. Question the order
2. Administer the medications
3. Administer separately
4. Contact the pharmacy

34. The best method of evaluating the amount of peripheral edema is:

1. Weighing the client daily
2. Measuring the extremity
3. Measuring the intake and output
4. Checking for pitting

35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

1. Overnight stays by family members is against hospital policy.
2. There is no need for him to stay because staffing is adequate.
3. His wife will rest much better knowing that he is at home.
4. Visitation is limited to 30 minutes when the implant is in place.

36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

1. Roast beef sandwich, potato chips, pickle spear, iced tea
2. Split pea soup, mashed potatoes, pudding, milk
3. Tomato soup, cheese toast, Jello, coffee
4. Hamburger, baked beans, fruit cup, iced tea

37.The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

1. "I will make sure I eat breakfast within 10 minutes of taking my insulin."
2. "I will need to carry candy or some form of sugar with me all the time."
3. "I will eat a snack around three o'clock each afternoon."
4. "I can save my dessert from supper for a bedtime snack."

38.The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:

1. New parents need time to learn how to hold the baby.
2. The umbilical cord needs time to separate.
3. Newborn skin is easily traumatized by washing.
4. The chance of chilling the baby outweighs the benefits of bathing.

39.A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

1. Treat iron-deficiency anemia caused by chemotherapeutic agents
2. Create a synergistic effect that shortens treatment time
3. Increase the number of circulating neutrophils
4. Reverse drug toxicity and prevent tissue damage

40..A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

1. Hib titer
2. Mumps vaccine
3. Hepatitis B vaccine
4. MMR

41.The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

1. 30 minutes before meals
2. With each meal
3. In a single dose at bedtime
4. 30 minutes after meals

42.A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

1. Call security for assistance and prepare to sedate the client.
2. Tell the client to calm down and ask him if he would like to play cards.
3. Tell the client that if he continues his behavior he will be punished.
4. Leave the client alone until he calms down.

43.When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

1. Check the client for bladder distention
2. Assess the blood pressure for hypotension
3. Determine whether an oxytocic drug was given
4. Check for the expulsion of small clots

44.A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:

1. Pneumonia
2. Reaction to antiviral medication
3. Tuberculosis
4. Superinfection due to low CD4 count

45.The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?

1. Diabetes
2. Prinzmetal's angina
3. Cancer
4. Cluster headaches

46.The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

1. Pain on flexion of the hip and knee
2. Nuchal rigidity on flexion of the neck
3. Pain when the head is turned to the left side
4. Dizziness when changing positions

47.The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

1. Agnosia
2. Apraxia
3. Anomia
4. Aphasia

48.The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

1. Chronic fatigue syndrome
2. Normal aging
3. Sundowning
4. Delusions

49.The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

1. "You know you had breakfast 30 minutes ago."
2. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."
3. "I'll get you some juice and toast. Would you like something else?"
4. "You will have to wait a while; lunch will be here in a little while."

50.The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

1. Urinary incontinence
2. Headaches
3. Confusion
4. Nausea

Answer Key NCLEX PRACTICE TEST 101

1. Answer D is correct. It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, answers A, B, and C are incorrect.

2. Answer D is correct. Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client. Therefore, answers A, B, and C are incorrect.

3. Answer B is correct. It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Answer A is incorrect because a mechanical cuff places too much pressure on the arm. Answer C is incorrect because raising the knee gatch impedes circulation. Answer D is incorrect because Tylenol is too mild an analgesic for the client in crisis.

4. Answer C is correct. Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in answers A, B, and D do not aid in hydration and are, therefore, incorrect.

5. Answer C is correct. The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Answer A is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Answer B is incorrect because although hydration is important, it would not require a bolus. Answer D is incorrect because Demerol is acidifying to the blood and increases sickling.

6. Answer C is correct. Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not; therefore, answers A, B, and D are incorrect.

7. Answer D is correct. Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided; therefore, answers A, B, and C are incorrect.

8. Answer D is correct. The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making answers A, B, and C incorrect.

9. Answer C is correct. The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, answer A is incorrect. The soles of the feet can be yellow if they are calloused, making answer B incorrect; the shins would be an area of darker pigment, so answer D is incorrect.

10. Answer B is correct. When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in answer B. The client with anemia is often pale in color, has weight loss, and may be hypotensive. Answers A, C, and D are within normal and, therefore, are incorrect.

11. Answer A is correct. The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Answers B, C, and D are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

12. Answer C is correct. Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, answers A and B are incorrect. Answer D is incorrect because the incidence of leukemia is higher in twins than in siblings.

13. Answer D is correct. Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petichiae. Answers A, B, and C are incorrect because the skin might be too dark to make an assessment.

14. Answer B is correct. The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations; therefore, answers A, C, and D are incorrect.

15. Answer B is correct. The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses in answers A, C, and D, which are incorrect.

16. Answer A is correct. Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Answers B, C, and D are incorrect because they are of lesser priority.

17. Answer A is correct. Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making answer A the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP; thus, answers B, C, and D are incorrect.

18. Answer A is correct. The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in answer C is important, but platelets do not carry oxygen. Answers B and D are of lesser priority and are incorrect in this instance.

19. Answer C is correct. Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Answers A, B, and D are incorrect because Trendelenburg, Valsalva maneuver, and coughing all increase the intracranial pressure.

20. Answer B is correct. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so answer A is incorrect. Encouraging fluid intake will not correct the problem, making answer C incorrect. Answer D is incorrect because weighing the client is not necessary at this time.

21. Answer C is correct. The client should be positioned upright and leaning forward, to prevent aspiration of blood. Answers A, B, and D are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.

22. Answer A is correct. Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders; therefore, answers B, C, and D are incorrect.

23. Answer A is correct. IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary; therefore, answers B, C, and D are incorrect.

24. Answer B is correct. The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, answer A is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so answers C and D are incorrect.

25. Answer D is correct. The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect.