kaplan Nclex review 100QUSTIONS ANSWRS & EXPLANATIONS
The nurse cares for a client who presents with
Ans: 4
confusion, mood lability, impaired communication, and
lethargy. The nurse should question which of the
(1) may be ordered to determine the presence of major depression
following orders?
(2) may be ordered to check for an endocrine cause for the symptoms before
1. Dexamethasone suppression test.
the diagnosis of dementia is made
2. Thyroid studies.
3.Drug toxicology screen.
(3)may be ordered to see if the client's symptoms are caused by excessive use
4.Trendelenburg test.
of medications or alcohol
(4)correct—test is used with a client who may have varicose veins, no
relationship to the symptoms described in this situation
A client has a total laryngectomy with a
Ans: 1
permanent tracheostomy. The nurse plans nutritional
intake for the next 3 days. Which of the following is
(1) correct—tube feedings frequently started as the initial nutritional
necessary for the nurse to consider regarding the
intake; prevents trauma to suture area
client's nutrition?
(2) although client has permanent tracheotomy, will be able to eat normally
1. To facilitate healing of the surgical area, a
after area has healed
nasogastric tube may be utilized and tube feedings
may be implemented.
(3)nutritional intake will begin when bowel sounds return and client can
2. The client will be unable to maintain any oral intake
tolerate intake
as long as the tracheotomy is in place.
3.Nutritional and/or gastric feedings will not be
(4)client is not dependent on ventilator
attempted for approximately 3 weeks to decrease
the incidence of aspiration.
4. Because the client is dependent on the
ventilator, nutritional intake will be delayed.
,For a client with a neurologic disorder, which of
Ans: 2
the following nursing assessments is MOST
helpful in determining subtle changes in the
(1) indicates increased intracranial pressure
client's level of consciousness?
(2) correct—Glasgow coma scale score best evaluates changes in a
1. Client posturing.
client's level of consciousness by evaluating eye-opening, motor, and verbal
2. Glasgow coma scale.
responses
3.Client thinking pattern.
4. Occurrence of hallucinations.
(3)more appropriate for the psychiatric client
(4)more appropriate for the psychiatric client
The nurse conducts a physical examination of a
Ans: 3
client suspected to have bulimia. Which of the
following observations by the nurse MOST likely
(1) common with anorexia
indicates bulimia?
(2) seen with anorexia
1. The client has edema of the lower extremities.
2. Physical exam of the client reveals the presence
(3)correct—due to frequent vomiting
of lanugo.
3. The client has ulcerated mucous membranes of
(4)bulimics are normal in appearance
the mouth.
4.The client has dry, yellowish color of the skin.
The nurse prepares a dopamine (Intropin) infusion on
Ans: 3
a client. Before beginning the infusion the nurse should
take which of the following actions?
(1) not a critical assessment at this time
1. Evaluate the urine output.
(2) contains correct information, but is not a priority
2. Obtain the client's weight.
3.Determine the patency of the IV line.
(3)correct—if extravasation occurs, there is sloughing of the surrounding skin and
4. Measure pulmonary artery pressures.
tissue; patent IV line is essential to prevent serious side effects
(4)not a critical assessment at this time
The nurse assists a nursing assistant in providing a bed
Ans: 1
bath to a comatose patient with incontinence. The
nurse should intervene if which of the following
(1) correct—contaminated gloves should be removed before answering the phone
actions is noted?
(2) correct way to roll a patient to maintain proper alignment
1. The nursing assistant answers the phone while
wearing gloves.
(3)appropriate to use incontinence pad for this patient
2. The nursing assistant log rolls the patient to
provide back care.
(4)appropriate position to prevent aspiration and protect the airway
3. The nursing assistant places an incontinent pad
under the patient.
4.The nursing assistant positions the patient on the
left side, head elevated.
, The nurse instructs a client who is receiving imipramine
Ans: 1
(Tofranil). It is MOST important for the nurse to instruct
the client to immediately report which of the
(1) correct—possible side effects of Tofranil, a tricyclic antidepressant
following?
medication, which can be resolved by altering the dosage or changing the
medication
1. Sore throat, fever, increased fatigue, vomiting, diarrhea.
2. Dry mouth, nasal stuffiness, weight gain.
(2) describes side effects of antidepressants, which client can learn to
3.Rapid heartbeat, frequent headaches, yellowing of
manage at home without changing the medication
eyes or skin.
4.Weakness, staggering gait, tremor, feeling
(3)not side effects of Tofranil
of drunkenness.
(4)not side effects of Tofranil
The nurse receives report from the previous shift. Which
Ans: 3
of the following patients should the nurse see FIRST?
(1) although the patient requires a high level of nursing care, no indication
1. A patient post coronary artery bypass graft (CABG)
that the patient is unstable
having the atrioventricular (AV) wires removed later in the
day.
(2) patient requires preoperative assessment and teaching, no indication that
2. A patient with type 1 diabetes scheduled for a cardiac
the patient is unstable
catheterization later today.
3. A patient 1 day postoperative with an epidural
(3)correct —epidural used for pain relief, monitor for urinary
catheter in place.
incontinence, hypotension, respiratory depression, and nausea and
4. A patient diagnosed with cardiomyopathy being
vomiting
evaluated for a heart transplant.
(4)requires monitoring but patient with epidural takes priority
A child has a closed transverse fracture of the right
Ans: 1
ulna. Which of the following actions, if performed by the
nurse before the application of a cast, is MOST
(1) correct—assess neurovascular status, check pain, pallor, paralysis,
important?
paresthesia, pulselessness
1. Check the radial pulses bilaterally and compare.
(2) assessment; temperature indicates decreased circulation but is subjective
2. Evaluate the skin temperature and tissue turgor in
and not most important
the area.
3. Assess sensation of each foot while the child closes
(3)assessment; upper (not lower) extremity fracture
her eyes.
4.Apply baby powder to decrease skin irritation under
(4)implementation; should not be done because it would increase skin irritation
the cast.
The nurse cares for a multipara client who delivered
Ans: 2
a female infant 1 hour ago. The nurse observes that the
client's breasts are soft; the uterus is boggy to the right
(1) encourage the client to void before catheterizing
of the midline and 2 cm below the umbilicus;
moderate lochia rubra. It is MOST important for the
(2) correct—boggy uterus deviated to right indicates full bladder, encourage
nurse to take which of the following actions?
client to void
1. Perform a straight catheterization.
(3)will increase uterine tone, but the problem is a full bladder
2. Offer the client the bedpan.
3.Put the baby to breast.
(4)findings indicate a full bladder
4. Massage the uterine fundus.
The nurse cares for a client who presents with
Ans: 4
confusion, mood lability, impaired communication, and
lethargy. The nurse should question which of the
(1) may be ordered to determine the presence of major depression
following orders?
(2) may be ordered to check for an endocrine cause for the symptoms before
1. Dexamethasone suppression test.
the diagnosis of dementia is made
2. Thyroid studies.
3.Drug toxicology screen.
(3)may be ordered to see if the client's symptoms are caused by excessive use
4.Trendelenburg test.
of medications or alcohol
(4)correct—test is used with a client who may have varicose veins, no
relationship to the symptoms described in this situation
A client has a total laryngectomy with a
Ans: 1
permanent tracheostomy. The nurse plans nutritional
intake for the next 3 days. Which of the following is
(1) correct—tube feedings frequently started as the initial nutritional
necessary for the nurse to consider regarding the
intake; prevents trauma to suture area
client's nutrition?
(2) although client has permanent tracheotomy, will be able to eat normally
1. To facilitate healing of the surgical area, a
after area has healed
nasogastric tube may be utilized and tube feedings
may be implemented.
(3)nutritional intake will begin when bowel sounds return and client can
2. The client will be unable to maintain any oral intake
tolerate intake
as long as the tracheotomy is in place.
3.Nutritional and/or gastric feedings will not be
(4)client is not dependent on ventilator
attempted for approximately 3 weeks to decrease
the incidence of aspiration.
4. Because the client is dependent on the
ventilator, nutritional intake will be delayed.
,For a client with a neurologic disorder, which of
Ans: 2
the following nursing assessments is MOST
helpful in determining subtle changes in the
(1) indicates increased intracranial pressure
client's level of consciousness?
(2) correct—Glasgow coma scale score best evaluates changes in a
1. Client posturing.
client's level of consciousness by evaluating eye-opening, motor, and verbal
2. Glasgow coma scale.
responses
3.Client thinking pattern.
4. Occurrence of hallucinations.
(3)more appropriate for the psychiatric client
(4)more appropriate for the psychiatric client
The nurse conducts a physical examination of a
Ans: 3
client suspected to have bulimia. Which of the
following observations by the nurse MOST likely
(1) common with anorexia
indicates bulimia?
(2) seen with anorexia
1. The client has edema of the lower extremities.
2. Physical exam of the client reveals the presence
(3)correct—due to frequent vomiting
of lanugo.
3. The client has ulcerated mucous membranes of
(4)bulimics are normal in appearance
the mouth.
4.The client has dry, yellowish color of the skin.
The nurse prepares a dopamine (Intropin) infusion on
Ans: 3
a client. Before beginning the infusion the nurse should
take which of the following actions?
(1) not a critical assessment at this time
1. Evaluate the urine output.
(2) contains correct information, but is not a priority
2. Obtain the client's weight.
3.Determine the patency of the IV line.
(3)correct—if extravasation occurs, there is sloughing of the surrounding skin and
4. Measure pulmonary artery pressures.
tissue; patent IV line is essential to prevent serious side effects
(4)not a critical assessment at this time
The nurse assists a nursing assistant in providing a bed
Ans: 1
bath to a comatose patient with incontinence. The
nurse should intervene if which of the following
(1) correct—contaminated gloves should be removed before answering the phone
actions is noted?
(2) correct way to roll a patient to maintain proper alignment
1. The nursing assistant answers the phone while
wearing gloves.
(3)appropriate to use incontinence pad for this patient
2. The nursing assistant log rolls the patient to
provide back care.
(4)appropriate position to prevent aspiration and protect the airway
3. The nursing assistant places an incontinent pad
under the patient.
4.The nursing assistant positions the patient on the
left side, head elevated.
, The nurse instructs a client who is receiving imipramine
Ans: 1
(Tofranil). It is MOST important for the nurse to instruct
the client to immediately report which of the
(1) correct—possible side effects of Tofranil, a tricyclic antidepressant
following?
medication, which can be resolved by altering the dosage or changing the
medication
1. Sore throat, fever, increased fatigue, vomiting, diarrhea.
2. Dry mouth, nasal stuffiness, weight gain.
(2) describes side effects of antidepressants, which client can learn to
3.Rapid heartbeat, frequent headaches, yellowing of
manage at home without changing the medication
eyes or skin.
4.Weakness, staggering gait, tremor, feeling
(3)not side effects of Tofranil
of drunkenness.
(4)not side effects of Tofranil
The nurse receives report from the previous shift. Which
Ans: 3
of the following patients should the nurse see FIRST?
(1) although the patient requires a high level of nursing care, no indication
1. A patient post coronary artery bypass graft (CABG)
that the patient is unstable
having the atrioventricular (AV) wires removed later in the
day.
(2) patient requires preoperative assessment and teaching, no indication that
2. A patient with type 1 diabetes scheduled for a cardiac
the patient is unstable
catheterization later today.
3. A patient 1 day postoperative with an epidural
(3)correct —epidural used for pain relief, monitor for urinary
catheter in place.
incontinence, hypotension, respiratory depression, and nausea and
4. A patient diagnosed with cardiomyopathy being
vomiting
evaluated for a heart transplant.
(4)requires monitoring but patient with epidural takes priority
A child has a closed transverse fracture of the right
Ans: 1
ulna. Which of the following actions, if performed by the
nurse before the application of a cast, is MOST
(1) correct—assess neurovascular status, check pain, pallor, paralysis,
important?
paresthesia, pulselessness
1. Check the radial pulses bilaterally and compare.
(2) assessment; temperature indicates decreased circulation but is subjective
2. Evaluate the skin temperature and tissue turgor in
and not most important
the area.
3. Assess sensation of each foot while the child closes
(3)assessment; upper (not lower) extremity fracture
her eyes.
4.Apply baby powder to decrease skin irritation under
(4)implementation; should not be done because it would increase skin irritation
the cast.
The nurse cares for a multipara client who delivered
Ans: 2
a female infant 1 hour ago. The nurse observes that the
client's breasts are soft; the uterus is boggy to the right
(1) encourage the client to void before catheterizing
of the midline and 2 cm below the umbilicus;
moderate lochia rubra. It is MOST important for the
(2) correct—boggy uterus deviated to right indicates full bladder, encourage
nurse to take which of the following actions?
client to void
1. Perform a straight catheterization.
(3)will increase uterine tone, but the problem is a full bladder
2. Offer the client the bedpan.
3.Put the baby to breast.
(4)findings indicate a full bladder
4. Massage the uterine fundus.
