NCLEX -Lippincott Final Exam LATEST VERSION.
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn.
To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items
from the diet? A-Lean Beef B-Air Pop Corn
C-Hot Chocolate D-Raw Vegetables
Correct: C
Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes
heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into
the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure
include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and
low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be
acceptable.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which
action should the nurse perform?
a) Sit with the client for a few minutes.
b) Administer an analgesic.
c) Inform the nurse manager.
d) Call the physician immediately.
CORRECT ANSWER d) Call the physician immediately. Reason: The nurse should notify the physician
immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the
client is appropriate but only after the physician has been notified of the change in the client's condition.
The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse
manager isn't necessary.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which
intervention will most likely lower the client's arterial blood oxygen saturation?
a) Endotracheal suctioning b) Encouragement of coughing c) Use of a cooling blanket d) Incentive
spirometry Check my Answer
CORRECT ANSWER a) Endotracheal suctioning Reason: Endotracheal suctioning removes secretions as
well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using
an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of
superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but
SaO2 levels wouldn't be affected.
,A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle
accident. His pain is not under control. The client states, "If I could be with my people, I could receive
acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based
on the theory that it:
a) Purges evil spirits. b) Promotes tranquility. c) Restores the balance of energy. d) Blocks nerve pathways
to the brain.
CORRECT ANSWER c) Restores the balance of energy. Reason: Acupuncture, like acumassage and
acupressure, is performed in certain Asian cultures to restore the energy balance within the body.
Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance.
Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can
promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many
researchers think that the gate-control theory of pain may explain the success of acupuncture,
acumassage, and acupressure.
A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in
the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could
the charting entry be best improved?
a) The entry should include clearer descriptions of the client's mood and behavior. b) The entry should
avoid mentioning cognitive or psychosocial issues. c) The entry should list the specific reasons that the
client was upset. d) The entry should specify the subsequent interventions that were performed.
a) The entry should include clearer descriptions of the client's mood and behavior. Reason: Entries in the
medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and
open to many interpretations. As such, the nurse should elaborate on this description so a reader has a
clearer understanding of the client's state of mind. Stating the apparent reasons that the client was
"upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid
components of the medical record. Responses and interventions should normally follow assessment data
but the data themselves must first be recorded accurately.
A nurse facilitated a mandated group therapy for clients who have sexually abused children. Children
who are victims of sexual abuse are typically?
a) from any segment of the population b) of low socioeconomic background. c) strangers to the abuser.
d) willing to engage in sexual acts with adults.
CORRECT ANSWER a) from any segment of the population. Reason: Victims of childhood sexual abuse
come from all segments of the population and from all socioeconomic backgrounds. Most victims know
their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full
decision-making capacities.
A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at
work and is being transported to the hospital by ambulance. Which of the following should the nurse do
upon the client's arrival?
a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital
signs every 4 hours. d) Admit the client to a quiet, darkened room.
,a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital
signs every 4 hours. d) Admit the client to a quiet, darkened room.
CORRECT ANSWER d) Admit the client to a quiet, darkened room. Reason: Because of her age and report
of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the
absence of any underlying cause. Although the actual cause is unknown, adolescents and women older
than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible.
Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should
be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops
after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema,
breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least
every hour.
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an
incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
a) The client will be maintained on bed rest for several days. b) Ambulation is restricted by the presence
of drainage tubes. c) The operative incision is near the diaphragm. d) The presence of a nasogastric tube
inhibits
CORRECT ANSWER c) The operative incision is near the diaphragm. Reason: The incisions made for upper
abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing
painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after
surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate
by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep
breathing and coughing.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having
difficulty breathing?
a) Diaphragmatic breathing
b) Use of accessory muscle
c) Pursed-lip breathing
d) Controlled breathing
CORRECT ANSWER
b) Use of accessory muscles Reason: The use of accessory muscles for respiration indicates the client is
having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing
techniques that help the client conserve energy.
When planning care for a client with a head injury, which position should the nurse include in the care
plan to enhance client outcomes?
a) Trendelenburg's b) 30-degree head elevation c) Flat d) Side-lying
, CORRECT ANSWER b) 30-degree head elevation Reason: For clients with increased intracranial pressure
(ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's
position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating
the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position
isn't specifically a therapeutic treatment for increased ICP
A nurse is developing a nursing diagnosis for a client. Which information should
a) Actions to achieve goals b) Expected outcomes c) Factors influencing the client's problem d) Nursing
history
CORRECT ANSWER
c) Factors influencing the client's problem Reason: A nursing diagnosis is a written statement describing a
client's actual or potential health problem. It includes a specified diagnostic label, factors that influence
the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve
goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse
develops during the evaluation step of the nursing process. The nurse obtains a nursing history during
the assessment step of the nursing process.
The nurse meets with the client and his wife to discuss depression and the client's medication. Which of
the following comments by the wife would indicate that the nurse's teaching about disease process and
medications has been effective?
a) "His depression is almost cured." b) "He's intelligent and won't need to depend on a pill much longer.
c) Ut's important for him to take his medication so that the depression will not return or get worse.d)
"It's important to watch for physical dependency on Zoloft."
CORRECT ANSWER c) "It's important for him to take his medication so that the depression will not return
or get worse." Reason: Improved balance of neurotransmitters is achieved with medication. Clients with
endogenous depression must take antidepressants to prevent a return or worsening of depressive
symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not
cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not
physically addictive.
A nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results
show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
a) start using insulin. b) start taking an oral antidiabetic drug. c) monitor her urine for glucose. d) be
taught about diet.
CORRECT ANSWER d) be taught about diet. Reason: The client will need to watch her overall diet intake
to control her blood glucose level. The client's blood glucose level should be controlled initially by diet
and exercise, rather than insulin. Oral antidiabetic drugs aren't used in pregnant clients. Urine glucose
levels aren't an accurate indication of blood glucose levels.
A nurse preceptor is working with a student nurse who is administering medications. Which statement
by the student indicates an understanding of the action of an antacid:
A client who has been diagnosed with gastroesophageal reflux disease (GERD) complains of heartburn.
To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items
from the diet? A-Lean Beef B-Air Pop Corn
C-Hot Chocolate D-Raw Vegetables
Correct: C
Reason: With GERD, eating substances that decrease lower esophageal sphincter pressure causes
heartburn. A decrease in the lower esophageal sphincter pressure allows gastric contents to reflux into
the lower end of the esophagus. Foods that can cause a decrease in esophageal sphincter pressure
include fatty foods, chocolate, caffeinated beverages, peppermint, and alcohol. A diet high in protein and
low in fat is recommended for clients with GERD. Lean beef, popcorn, and raw vegetables would be
acceptable.
A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which
action should the nurse perform?
a) Sit with the client for a few minutes.
b) Administer an analgesic.
c) Inform the nurse manager.
d) Call the physician immediately.
CORRECT ANSWER d) Call the physician immediately. Reason: The nurse should notify the physician
immediately because the headache may be an indication that the aneurysm is leaking. Sitting with the
client is appropriate but only after the physician has been notified of the change in the client's condition.
The physician will decide whether or not administration of an analgesic is indicated. Informing the nurse
manager isn't necessary.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which
intervention will most likely lower the client's arterial blood oxygen saturation?
a) Endotracheal suctioning b) Encouragement of coughing c) Use of a cooling blanket d) Incentive
spirometry Check my Answer
CORRECT ANSWER a) Endotracheal suctioning Reason: Endotracheal suctioning removes secretions as
well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using
an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of
superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but
SaO2 levels wouldn't be affected.
,A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle
accident. His pain is not under control. The client states, "If I could be with my people, I could receive
acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based
on the theory that it:
a) Purges evil spirits. b) Promotes tranquility. c) Restores the balance of energy. d) Blocks nerve pathways
to the brain.
CORRECT ANSWER c) Restores the balance of energy. Reason: Acupuncture, like acumassage and
acupressure, is performed in certain Asian cultures to restore the energy balance within the body.
Pressure, massage, and fine needles are applied to energy pathways to help restore the body's balance.
Acupuncture is not based on a belief in purging evil spirits. Although pain relief through acupuncture can
promote tranquility, acupuncture is performed to restore energy balance. In the Western world, many
researchers think that the gate-control theory of pain may explain the success of acupuncture,
acumassage, and acupressure.
A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in
the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could
the charting entry be best improved?
a) The entry should include clearer descriptions of the client's mood and behavior. b) The entry should
avoid mentioning cognitive or psychosocial issues. c) The entry should list the specific reasons that the
client was upset. d) The entry should specify the subsequent interventions that were performed.
a) The entry should include clearer descriptions of the client's mood and behavior. Reason: Entries in the
medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and
open to many interpretations. As such, the nurse should elaborate on this description so a reader has a
clearer understanding of the client's state of mind. Stating the apparent reasons that the client was
"upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid
components of the medical record. Responses and interventions should normally follow assessment data
but the data themselves must first be recorded accurately.
A nurse facilitated a mandated group therapy for clients who have sexually abused children. Children
who are victims of sexual abuse are typically?
a) from any segment of the population b) of low socioeconomic background. c) strangers to the abuser.
d) willing to engage in sexual acts with adults.
CORRECT ANSWER a) from any segment of the population. Reason: Victims of childhood sexual abuse
come from all segments of the population and from all socioeconomic backgrounds. Most victims know
their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full
decision-making capacities.
A 16-year-old primigravida at 36 weeks' gestation who has had no prenatal care experienced a seizure at
work and is being transported to the hospital by ambulance. Which of the following should the nurse do
upon the client's arrival?
a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital
signs every 4 hours. d) Admit the client to a quiet, darkened room.
,a) Position the client in a supine position. b) Auscultate breath sounds every 4 hours. c) Monitor the vital
signs every 4 hours. d) Admit the client to a quiet, darkened room.
CORRECT ANSWER d) Admit the client to a quiet, darkened room. Reason: Because of her age and report
of a seizure, the client is probably experiencing eclampsia, a condition in which convulsions occur in the
absence of any underlying cause. Although the actual cause is unknown, adolescents and women older
than 35 years are at higher risk. The client's environment should be kept as free of stimuli as possible.
Thus, the nurse should admit the client to a quiet, darkened room. Clients experiencing eclampsia should
be kept on the left side to promote placental perfusion. In some cases, edema of the lungs develops
after seizures and is a sign of cardiovascular failure. Because the client is at risk for pulmonary edema,
breath sounds should be monitored every 2 hours. Vital signs should be monitored frequently, at least
every hour.
Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an
incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area?
a) The client will be maintained on bed rest for several days. b) Ambulation is restricted by the presence
of drainage tubes. c) The operative incision is near the diaphragm. d) The presence of a nasogastric tube
inhibits
CORRECT ANSWER c) The operative incision is near the diaphragm. Reason: The incisions made for upper
abdominal surgeries, such as cholecystectomies, are near the diaphragm and make deep breathing
painful. Incentive spirometry, which encourages deep breathing, is essential to prevent atelectasis after
surgery. The client is not maintained on bed rest for several days. The client is encouraged to ambulate
by the first postoperative day, even with drainage tubes in place. Nasogastric tubes do not inhibit deep
breathing and coughing.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having
difficulty breathing?
a) Diaphragmatic breathing
b) Use of accessory muscle
c) Pursed-lip breathing
d) Controlled breathing
CORRECT ANSWER
b) Use of accessory muscles Reason: The use of accessory muscles for respiration indicates the client is
having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing
techniques that help the client conserve energy.
When planning care for a client with a head injury, which position should the nurse include in the care
plan to enhance client outcomes?
a) Trendelenburg's b) 30-degree head elevation c) Flat d) Side-lying
, CORRECT ANSWER b) 30-degree head elevation Reason: For clients with increased intracranial pressure
(ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's
position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating
the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position
isn't specifically a therapeutic treatment for increased ICP
A nurse is developing a nursing diagnosis for a client. Which information should
a) Actions to achieve goals b) Expected outcomes c) Factors influencing the client's problem d) Nursing
history
CORRECT ANSWER
c) Factors influencing the client's problem Reason: A nursing diagnosis is a written statement describing a
client's actual or potential health problem. It includes a specified diagnostic label, factors that influence
the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve
goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse
develops during the evaluation step of the nursing process. The nurse obtains a nursing history during
the assessment step of the nursing process.
The nurse meets with the client and his wife to discuss depression and the client's medication. Which of
the following comments by the wife would indicate that the nurse's teaching about disease process and
medications has been effective?
a) "His depression is almost cured." b) "He's intelligent and won't need to depend on a pill much longer.
c) Ut's important for him to take his medication so that the depression will not return or get worse.d)
"It's important to watch for physical dependency on Zoloft."
CORRECT ANSWER c) "It's important for him to take his medication so that the depression will not return
or get worse." Reason: Improved balance of neurotransmitters is achieved with medication. Clients with
endogenous depression must take antidepressants to prevent a return or worsening of depressive
symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not
cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not
physically addictive.
A nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results
show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to:
a) start using insulin. b) start taking an oral antidiabetic drug. c) monitor her urine for glucose. d) be
taught about diet.
CORRECT ANSWER d) be taught about diet. Reason: The client will need to watch her overall diet intake
to control her blood glucose level. The client's blood glucose level should be controlled initially by diet
and exercise, rather than insulin. Oral antidiabetic drugs aren't used in pregnant clients. Urine glucose
levels aren't an accurate indication of blood glucose levels.
A nurse preceptor is working with a student nurse who is administering medications. Which statement
by the student indicates an understanding of the action of an antacid:
