Saunders NCLEX-RN Test Bank
Questions And Answers Practice
Questions with Solutions Newest |
Already Graded A+
1. A nurse is caring for a client with heart failure. On
assessment, the nurse notes that the client is dyspneic, and
crackles are audible on auscultation. What additional
manifestations would the nurse expect to note in this client if
excess fluid volume is present?
A) Weight loss and dry skin
B) Flat neck and hand veins and decreased urinary output
C) An increase in blood pressure and increased respirations
D) Weakness and decreased central venous pressure (CVP)
Answer: C) An increase in blood pressure and increased
respirations
Rationale: A fluid volume excess (overhydration) occurs when
fluid intake or retention exceeds the body's needs. Manifestations
include cough, dyspnea, crackles, tachypnea, tachycardia, elevated
blood pressure, bounding pulse, elevated CVP, weight gain,
edema, neck and hand vein distention, altered LOC, and
decreased hematocrit. Dry skin, flat neck and hand veins,
decreased urinary output, and decreased CVP are noted in fluid
,volume deficit. Weakness can be present in either fluid volume
excess or deficit.
2. A client who has just received a diagnosis of asthma says to
the nurse, "This is just another nail in my coffin." Which
response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a
challenge rather than a 'nail in your coffin.'"
D) "Asthma is a very treatable condition, but it's important to
learn how to properly administer your medications. Let's practice
with your inhalant."
Answer: B) "You seem very distressed at learning that you
have asthma."
Rationale: The therapeutic response acknowledges the client's
feelings and encourages further expression of emotions. Option A
is confrontational and may increase anxiety. Option C is
judgmental and nontherapeutic. Option D, while informative, does
not address the client's emotional distress.
3. A postpartum nurse is caring for a client who had a
placenta previa. Which nursing intervention does the nurse
identify as the priority for this client?
A) Fundal assessment
B) Monitoring of urine output
C) Frequent assessment of lochia
D) Inclusion of iron in every meal
Answer: C) Frequent assessment of lochia
Rationale: In placenta previa, the placenta is implanted in the
,lower uterine segment, which is more prone to bleeding even
when the fundus is firm. The nurse may first see an increase in
lochia as a sign of hemorrhage. The client must then be assessed
carefully for signs of deficient fluid volume as a result of
postpartum hemorrhage. This assessment includes urine output
and fundal assessment; however, these are not the priority.
Dietary intake of iron is not related specifically to placenta previa.
4. The nurse notes that a client's cardiac rhythm shows absent
P waves, no PR interval, and an irregular rhythm. How should
the nurse interpret this rhythm?
A) Bradycardia
B) Tachycardia
C) Atrial fibrillation
D) Normal sinus rhythm (NSR)
Answer: C) Atrial fibrillation
Rationale: In atrial fibrillation, the P waves are absent and
replaced by fibrillatory waves. There is no PR interval, and the QRS
duration usually is normal and constant, with an irregular rhythm.
Bradycardia is a slowed heart rate, and tachycardia is a fast heart
rate. In NSR, a P wave precedes each QRS complex, the rhythm is
essentially regular, the PR interval is 0.12 to 0.20 second, and the
QRS interval is 0.06 to 0.10 second.
5. A rubella titer is performed on a woman who has just been
told that she is pregnant. The results of the titer indicate that
the mother is not immune to rubella. The nurse tells the client
that:
A) A therapeutic abortion should be considered.
B) Immunization against rubella is required immediately.
, C) Immunization against rubella is required after delivery.
D) Antibiotics will be prescribed to prevent the infection.
Answer: C) Immunization against rubella is required after
delivery.
Rationale: A rubella titer is performed to determine the pregnant
client's immunity to rubella. If the titer is less than 1:8, the woman
is not immune. The client is then immunized after delivery
because the vaccine contains live virus and should not be
administered during pregnancy. Antibiotics are not prescribed.
Counseling the client on therapeutic abortion is incorrect.
6. A charge nurse is making client assignments on a medical-
surgical unit. Which client should be assigned to the most
experienced registered nurse (RN)?
A) A 45-year-old with type 2 diabetes requiring a dressing change
for a foot ulcer.
B) A 60-year-old 2 days post-operative following a total knee
replacement who is using a patient-controlled analgesia (PCA)
pump.
C) A 55-year-old newly admitted with unstable vital signs and
gastrointestinal bleeding.
D) A 30-year-old with pneumonia receiving IV antibiotics every 8
hours.
Answer: C) A 55-year-old newly admitted with unstable vital
signs and gastrointestinal bleeding.
Rationale: Client acuity and stability determine assignment. The
unstable client with gastrointestinal bleeding requires the most
experienced nurse due to the potential for rapid decompensation
Questions And Answers Practice
Questions with Solutions Newest |
Already Graded A+
1. A nurse is caring for a client with heart failure. On
assessment, the nurse notes that the client is dyspneic, and
crackles are audible on auscultation. What additional
manifestations would the nurse expect to note in this client if
excess fluid volume is present?
A) Weight loss and dry skin
B) Flat neck and hand veins and decreased urinary output
C) An increase in blood pressure and increased respirations
D) Weakness and decreased central venous pressure (CVP)
Answer: C) An increase in blood pressure and increased
respirations
Rationale: A fluid volume excess (overhydration) occurs when
fluid intake or retention exceeds the body's needs. Manifestations
include cough, dyspnea, crackles, tachypnea, tachycardia, elevated
blood pressure, bounding pulse, elevated CVP, weight gain,
edema, neck and hand vein distention, altered LOC, and
decreased hematocrit. Dry skin, flat neck and hand veins,
decreased urinary output, and decreased CVP are noted in fluid
,volume deficit. Weakness can be present in either fluid volume
excess or deficit.
2. A client who has just received a diagnosis of asthma says to
the nurse, "This is just another nail in my coffin." Which
response by the nurse is therapeutic?
A) "Do you think that having asthma will kill you?"
B) "You seem very distressed at learning that you have asthma."
C) "I'm not going to work with you if you can't view this as a
challenge rather than a 'nail in your coffin.'"
D) "Asthma is a very treatable condition, but it's important to
learn how to properly administer your medications. Let's practice
with your inhalant."
Answer: B) "You seem very distressed at learning that you
have asthma."
Rationale: The therapeutic response acknowledges the client's
feelings and encourages further expression of emotions. Option A
is confrontational and may increase anxiety. Option C is
judgmental and nontherapeutic. Option D, while informative, does
not address the client's emotional distress.
3. A postpartum nurse is caring for a client who had a
placenta previa. Which nursing intervention does the nurse
identify as the priority for this client?
A) Fundal assessment
B) Monitoring of urine output
C) Frequent assessment of lochia
D) Inclusion of iron in every meal
Answer: C) Frequent assessment of lochia
Rationale: In placenta previa, the placenta is implanted in the
,lower uterine segment, which is more prone to bleeding even
when the fundus is firm. The nurse may first see an increase in
lochia as a sign of hemorrhage. The client must then be assessed
carefully for signs of deficient fluid volume as a result of
postpartum hemorrhage. This assessment includes urine output
and fundal assessment; however, these are not the priority.
Dietary intake of iron is not related specifically to placenta previa.
4. The nurse notes that a client's cardiac rhythm shows absent
P waves, no PR interval, and an irregular rhythm. How should
the nurse interpret this rhythm?
A) Bradycardia
B) Tachycardia
C) Atrial fibrillation
D) Normal sinus rhythm (NSR)
Answer: C) Atrial fibrillation
Rationale: In atrial fibrillation, the P waves are absent and
replaced by fibrillatory waves. There is no PR interval, and the QRS
duration usually is normal and constant, with an irregular rhythm.
Bradycardia is a slowed heart rate, and tachycardia is a fast heart
rate. In NSR, a P wave precedes each QRS complex, the rhythm is
essentially regular, the PR interval is 0.12 to 0.20 second, and the
QRS interval is 0.06 to 0.10 second.
5. A rubella titer is performed on a woman who has just been
told that she is pregnant. The results of the titer indicate that
the mother is not immune to rubella. The nurse tells the client
that:
A) A therapeutic abortion should be considered.
B) Immunization against rubella is required immediately.
, C) Immunization against rubella is required after delivery.
D) Antibiotics will be prescribed to prevent the infection.
Answer: C) Immunization against rubella is required after
delivery.
Rationale: A rubella titer is performed to determine the pregnant
client's immunity to rubella. If the titer is less than 1:8, the woman
is not immune. The client is then immunized after delivery
because the vaccine contains live virus and should not be
administered during pregnancy. Antibiotics are not prescribed.
Counseling the client on therapeutic abortion is incorrect.
6. A charge nurse is making client assignments on a medical-
surgical unit. Which client should be assigned to the most
experienced registered nurse (RN)?
A) A 45-year-old with type 2 diabetes requiring a dressing change
for a foot ulcer.
B) A 60-year-old 2 days post-operative following a total knee
replacement who is using a patient-controlled analgesia (PCA)
pump.
C) A 55-year-old newly admitted with unstable vital signs and
gastrointestinal bleeding.
D) A 30-year-old with pneumonia receiving IV antibiotics every 8
hours.
Answer: C) A 55-year-old newly admitted with unstable vital
signs and gastrointestinal bleeding.
Rationale: Client acuity and stability determine assignment. The
unstable client with gastrointestinal bleeding requires the most
experienced nurse due to the potential for rapid decompensation
