Exam (elaborations) HESI A2 NCLEX-RN TEST PREP QUESTIONS AND ANSWERS WITH EXPLANATIONS

NCLEX RN TEST PREP QUESTIONS AND ANSWERS WITH EXPLANATIONS IT COVERS: 1. BASIC NURSING CARE-171 2. MANAGEMENT AND PRACTICE DIRECTIVES- 115 3. PREVENTING RISKS AND COMPLICATIONS-81 4. CARING FOR ACUTE OR CHRONIC C.ONDITIONS-97 5. SAFETY -68 6. MENTAL HEALTH -49 7. PHARMACOLOGY 114 8. GROWTH AND DEVELOPMENT-66 BASIC NURSING CARE (STUDY MODE) 1. In which of the following ways can the nurse promote the sense of taste for an older adult? a. Mix foods together on the dinner tray b. Avoid cologne, air fresheners, or room deodorizers c. Encourage the client to chew food thoroughly d. Discourage the use of salt or seasonings with prepared food ANSWER C: As clients age, their sense of taste may diminish, reducing the S - The Marketplace to Buy and Sell your Study Material joy that comes with eating. A nurse can promote the sense of taste for a client by encouraging him to chew his food thoroughly while eating. This results in longer contact of food with the taste buds and a greater chance of tasting the food. 2. Which of the following is classified as a prerenal condition that affects urinary elimination? a. Nephrotoxic medications b. Pericardial tamponade c. Neurogenic bladder d. Polycystic kidney disease S - The Marketplace to Buy and Sell your Study Material ANSWER B: A prerenal condition is that which causes reduced urinary elimination due to a diminished blood flow to the kidneys. A condition such as cardiac tamponade affects the heart's ability to pump adequate amounts of blood, thereby reducing blood flow to vital organs throughout the body, including the kidneys. 3. A nurse is assessing an African American client for risks of a pressure ulcer. Which of the following best describes what the nurse might find with an early pressure ulcer in this client? a. Skin has a purple/bluish color b. Capillary refill is 1 second c. Skin appears blanched at the pressure site d. Tenting appears when checking skin turgor ANSWER A: When assessing for signs of developing pressure ulcers in a client with dark skin, decreased circulation may not always be readily apparent. For instance, blanching, the red undertones seen in light-skinned clients, will not always be present. Instead, the skin of an early pressure ulcer may develop a purple or bluish color. 4. A term used to refer to generalized wasting of body tissues and malnutrition is called: a. Entropion b. Confabulation c. Induration d. Cachexia S - The Marketplace to Buy and Sell your Study Material ANSWER D: Cachexia is a term used to describe the generalized wasting of body tissues, ill health, and malnutrition that is associated with some chronic diseases. Cachexia involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers in addition to complications associated with malnutrition and poor health. 5. Which of the following clients is at a higher risk of developing oral health problems? a. A pregnant client b. A client with diabetes c. A client receiving chemotherapy d. Both b and c ANSWER D: Some clients are at higher risk of developing oral health problems due to changes in the mouth associated with certain diseases, or an inability to provide proper self care and oral hygiene. Diabetic clients may be more likely to develop periodontal disease, gingivitis, or mouth dryness. Clients receiving chemotherapy may have mouth ulcers or gingivitis, leading to further pain and infection. 6. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client? a. Loosen pressure dressings on wounds b. Use assistance to pull a client up in bed c. Check temperature of water used in a sponge bath S - The Marketplace to Buy and Sell your Study Material d. Position the client prone ANSWER C: A nurse can reduce environmental stimuli that can cause discomfort for a client through several interventions. When giving a sponge bath, the nurse can check the temperature of the bath water to ensure it is not too hot to avoid burns, nor too cold, to avoid causing discomfort. Other measures the nurse can perform include lifting clients rather than pulling them up in bed, changing wet dressings, and providing proper positioning while in bed. 7. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition? a. Cracks at the corners of the mouth b. Altered mental status c. Bleeding gums and loose teeth d. Anorexia and diarrhea ANSWER C: A client with a severe vitamin C deficiency has a condition called scurvy. Clients with scurvy are most likely to develop bleeding gums, loose teeth, poor wound healing, and easy bruising. 8. Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity? a. Turn the client at least every 8 hours b. Apply lotion to the skin before a bath S - The Marketplace to Buy and Sell your Study Material c. Provide perineal care after the client uses the bathroom d. Bathe the client every 3 days ANSWER C: A nurse can help protect the skin integrity of some clients, especially female clients who are incontinent, by performing cares that keep the skin clean and dry. Providing perineal care after the client uses the bathroom promotes good skin integrity by removing excess secretions that could cause odor and infection. 9. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANSWER C: A client in stage 3 of the sleep cycle has moved into deeper stages of sleep and is more difficult to arouse. The client may have relaxed muscles, a decrease in vital signs, and may lie very still. Stage 3 of sleep is a type of non-REM sleep in which the client progresses toward REM sleep and vivid dreams. 10. A nurse is assisting a client who uses an intraaural hearing aid. Once the aid has been placed in the ear, it begins to whistle. What is the next action of the nurse? S - The Marketplace to Buy and Sell your Study Material a. Try to reposition the hearing aid b. Change the batteries c. Remove the device and have it cleaned d. Notify the physician that the hearing aid is not working ANSWER A: An intraaural hearing aid, sometimes called an in-the-ear hearing aid, is one that is placed in the ear canal. When positioning the hearing aid, a whistling sound indicates it may be positioned improperly. If whistling sounds begin after placement, the nurse should try to reposition the hearing aid. 11. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process? a. Use sterile solution from the refrigerator b. Position the client in the prone position c. Clamp the catheter at the level above the injection port d. Inject sterile solution through the injection port into the catheter ANSWER D: When performing a closed intermittent system of catheter irrigation, the nurse should draw up sterile solution that has been at room temperature using sterile technique. The client should be positioned for easy access to the catheter site and to assess the abdomen during the procedure. After clamping the tubing below the level of the injection port and cleansing the site, the nurse injects fluid into the port, which travels up the catheter to irrigate the tubing and the bladder. S - The Marketplace to Buy and Sell your Study Material 12. Which of the following is a negative outcome associated with impaired mobility? a. Increased amounts of calcium are absorbed from circulation b. A drop in blood pressure occurs when rising from a sitting to a standing position c. The amount of mucous in the bronchi and lungs decreases d. The vessel walls of the circulatory system thicken ANSWER B: A client with impaired mobility may develop many changes in body systems that put him at risk of further illness or injury. Orthostatic hypotension occurs when blood pressure drops more than 25 mmHg systolic or 10 mmHg diastolic upon rising from a sitting or lying position to standing. Orthostatic hypotension may develop in the client with impaired mobility when blood circulates more slowly or pools in the distal extremities. 13. A nurse is caring for a client who died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since his death. Which of the following processes explains this phenomenon? a. Rigor mortis b. Postmortem decomposition c. Algor mortis d. Livor mortis ANSWER C: Algor mortis occurs after death when the body's circulation stops and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room S - The Marketplace to Buy and Sell your Study Material temperature. The client's skin gradually loses its elasticity during this time. 14. A nurse is calculating a client's intake and output. During the last shift, the client has had ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client has urinated 250 cc and has had 2 bowel movements. What is this client's intake and output for this shift? a. 420 cc intake, 250 cc output b. 300 cc intake, 250 cc output c. 550 cc intake, 550 cc output d. 300 cc intake, 550 cc output ANSWER A: This client has had a 420 cc intake and 250 cc output during the last shift. One-half cup of liquid, such as gelatin, is approximately 120 cc, which should be added to the 300 cc of water ingested. The nurse does not convert food to cc's, although hospital protocol may dictate documentation of the amount of food eaten, such as one whole chicken breast or a cup of beans. Output is urine in ccs, which is 250 cc in this shift. The nurse may measure output of vomit, diarrhea, or gastric suction. Formed bowel movements are not converted to ccs, but the nurse may need to document the number of client stools. 15. A nurse is caring for a client with ariboflavinosis. Which of the following foods should the nurse serve this client? a. Citrus fruits b. Milk S - The Marketplace to Buy and Sell your Study Material c. Fish d. Potatoes ANSWER B: Ariboflavinosis is a vitamin B-2 deficiency. The client may develop cracks around the mouth, inflammation of the tongue, or sensitivity to light. The nurse should serve foods that are good sources of vitamin B-2, including milk, liver, green vegetables, or whole grains. 16. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent? a. Reflex incontinence b. Urge incontinence c. Total incontinence d. Functional incontinence ANSWER D: Functional incontinence occurs when a client develops an urge to void but may not be able to reach the toilet in time. Functional incontinence may be related to conditions that cause the client to forget bladder sensation until the last minute, such as cognitive changes; or the client may have mobility problems that prevent her from reaching the bathroom in time. 17. Which of the following is part of client teaching regarding anti-embolism stockings? S - The Marketplace to Buy and Sell your Study Material a. Instruct the client to roll the top portion of the stocking down if it is too long b. Stockings are applied with the toes uncovered at the end c. Measure for thigh-high stockings from the foot to the knee d. Stockings are to be smooth from end to end without wrinkles ANSWER D: Anti-embolism stockings are often applied for clients who have surgery or those with mobility problems. Anti-embolism stockings reduce the chance of blood clot formation in the legs. When applying the stockings, the nurse should teach the client that the stockings should be free from wrinkles from end to end, as wrinkles can impair circulation. 18. Which of the following reasons is the most likely cause of constipation in a client? a. Postponing bowel movement when the urge to defecate occurs b. Intestinal infection c. Antibiotic use d. Food allergies ANSWER A: Clients who postpone bowel movements by either ignoring the urge to defecate or not evacuating for some reason like not being near a bathroom may be at higher risk of developing constipation. This causes a decrease in the frequency of bowel movements, slowed motility of the intestinal tract, and increased absorption of fecal water, contributing to hard, dry stools that are difficult to pass. 19. S - The Marketplace to Buy and Sell your Study Material Which of the following statements best describes footdrop? a. The foot is permanently fixed in the dorsiflexion position b. The foot is permanently fixed in the plantar flexion position c. The toes of the foot are permanently fanned d. The heel of the foot is permanently rotated outward ANSWER B: Footdrop results in the foot becoming permanently fixed in a plantar flexion position. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. 20. A nurse is assisting a client with range of motion exercises. She moves his leg in a pattern of circumduction. Which movement is this nurse performing? a. Bending the leg at the knee b. Turning the foot inward and outward c. Moving the leg in a circle d. Moving the leg forward and up ANSWER C: Circumduction is the process of moving a limb in a circle. In this case, circumduction of the leg is a range of motion exercise where the nurse moves the leg in a circle, working the muscles of the gluteus maximus and gluteus medius. 21. A nurse is assisting a client to lie in the Sims' position. In what position does S - The Marketplace to Buy and Sell your Study Material the nurse arrange the client? a. The client lies on his side with the upper leg flexed b. The client lies on his back with his head lower than his feet c. The client lies on his abdomen with a pillow supporting his head d. The client is sitting up at a 90-degree angle ANSWER A: The Sims' position is a side-lying position for clients that may be used for examinations or to lie comfortably. The Sims' position involves aligning the client to lie on his side with his abdomen slightly downward. The upper leg is flexed, while the lower arm under the client is positioned behind his body. A pillow may be used to support the leg. 22. A nurse is instructing a client about how to use his crutches. Which of the following information should the nurse include in her teaching? a. Place the majority of body weight on the axilla b. Dry crutch tips with a paper towel if they become wet c. Use the crutches for support to lift both feet simultaneously when ascending stairs d. Both a and b ANSWER B: When instructing a client as to how to use crutches for ambulation, the nurse should teach the client the importance of keeping the crutch tips dry. If the tips become wet, the client could slip while supporting his weight on the crutches. The nurse can teach the client to inspect the crutch tips for moisture and dry them with a paper towel if they become wet. S - The Marketplace to Buy and Sell your Study Material 23. Which of the following is a disadvantage of using a dry heat application? a. Dry heat is more likely to cause burns than moist heat b. Dry heat penetrates deeply into the tissues c. Dry heat causes the skin to dry out more quickly d. Dry heat can quickly cause skin breakdown ANSWER C: When applying a heat application for therapy, the nurse often has a choice between moist or dry applications. Dry applications may be less likely to cause burns and are less likely to contribute to skin breakdown. However, dry heat applications do not penetrate deeply into the tissues and may cause the skin to dry out more quickly. 24. A nurse is preparing to administer an enema to a 64-year old client. Which of the following actions of the nurse is most appropriate? a. Assist the client to lie in the semi-Fowler position b. Apply lubricating jelly to the tip of the catheter before insertion c. Instill a total of 30cc of fluid into the client's rectum d. Ask the client to hold the solution in for 30 seconds ANSWER B: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. Lubricating the tip of the catheter, the nurse should instill a maximum of 750 to 1000 cc of fluid for an adult client. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes. S - The Marketplace to Buy and Sell your Study Material 25. Which of the following is an example of a positive effect of exercise on a client? a. Decreased basal metabolic rate b. Decreased venous return c. Decreased work of breathing d. Decreased gastric motility ANSWER C: There are many positive benefits that clients can derive from exercise, including increased metabolic rate, increased gastric motility, and increased venous return. Exercise decreases a client's work of breathing, such that regular activities require less effort. 26. A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from? a. Cataracts b. Glaucoma c. Astigmatism d. Presbyopia ANSWER D: Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. S - The Marketplace to Buy and Sell your Study Material 27. A nurse is caring for Mrs. T, a client with expressive aphasia. During a bath, she begins to gesture wildly and point toward the bath water, yet is unable to say anything. Which response from the nurse is most appropriate? a. Is something wrong with the bath water?" b. Just calm down, we'll finish your bath soon." c. Are you trying to tell me something?" d. Shall I turn on the television?" ANSWER A: A client with expressive aphasia can understand when others speak to her, but may be unable to form the correct words or phrases to respond. In this situation, the client is obviously trying to tell the nurse something, but cannot get the words out. The nurse should try to pinpoint the subject the client is trying to bring up. 28. A nurse is assisting a client with shampooing his hair while he is still in bed. While helping the client, the nurse raises the bed to approximately the level of her waist. What is the rationale for this action? a. To prevent shampoo from getting into the client's eyes b. To allow excess water to run off the edge of the bed c. To decrease strain on the nurse's back d. To prevent the client's hair from developing tangles ANSWER C: When assisting a client with activities of daily living in which the client remains in bed, the nurse may raise the bed to a level that is appropriate for working. This reduces strain on the nurse's back and legs when she must stand at the bedside to assist the client. S - The Marketplace to Buy and Sell your Study Material 29. Which of the following signs or symptoms indicates a possible nutritional deficiency? a. Subcutaneous fat at the waist and abdomen b. Presence of papillae on the surface of the tongue c. Straight arms and legs d. Pale conjunctiva ANSWER D: A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. 30. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube? a. From the tip of the nose to the xiphoid process b. From the tip of the nose to the earlobe to the xiphoid process c. From the earlobe to the xiphoid process d. From the tip of the nose to the earlobe to the umbilicus ANSWER B: When preparing to insert a nasogastric tube, the nurse must measure for the correct length to ensure that the end of the tube will be in the correct position in the stomach. To gauge the correct length, the nurse should measure from the tip of the nose to the earlobe to the xiphoid process. This S - The Marketplace to Buy and Sell your Study Material length puts the end of the tube in the stomach, rather than the small intestine or esophagus. 31. In which of the following ways can a nurse promote sleep for a client who is experiencing insomnia? a. Assist the client to use the bathroom one hour after going to bed b. Give the client a massage after he wakes up in the morning c. Tuck bed sheets and blankets tightly around the client once he is settled in bed d. Give the client a pair of socks to wear if his feet become cold ANSWER D: A nurse can promote sleep for a client who suffers from insomnia by removing any barriers that may contribute to sleeplessness. If a client develops cold feet, the nurse can give him a pair of socks or an extra blanket to keep his feet warm. Caring for small measures such as these may make a difference in a client's comfort level, promoting sleep. 32. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as: a. Referred pain b. Superficial pain c. Radiating pain d. Precipitating pain ANSWER C: Radiating pain is that type of pain that starts in one part of the S - The Marketplace to Buy and Sell your Study Material body and travels to other related areas. Examples of radiating pain include pain that travels along an extremity or pain that moves from the front of the body toward the back. Radiating pain may be constant or it may come and go. 33. A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is: a. Hesitancy b. Oliguria c. Retention d. Urgency ANSWER A: Urinary hesitancy occurs when a client has difficulty with starting a flow of urine while using the bathroom. Hesitancy may be due to physiological factors, such as obstruction from an enlarged prostate, or due to psychological factors, such as anxiety or embarrassment. 34. A nurse is preparing to irrigate a client's colostomy. Which of the following situations is a contraindication for this type of irrigation? a. The client has an incontinent ostomy b. The client has an irregular bowel routine c. The client has diverticulitis d. The colostomy bag contains fecal material ANSWER C: A client with a colostomy may need irrigation of the site on a S - The Marketplace to Buy and Sell your Study Material regular basis to clear gas from the colon and reduce odor. There are some situations, however, when irrigation is contraindicated, such as when the client has a gastrointestinal illness that would be exacerbated by irrigation, such as diverticulitis. 35. Which of the following statements best describes substance P? a. Substance P decreases a client's sensitivity to pain b. Substance P levels are drawn before administration of narcotic analgesics c. Substance P is found in the brain and is responsible for pain control and management of depression d. Substance P is found in the dorsal horn of the spinal column ANSWER D: Substance P is a type of neurotransmitter that is found in the brain and the dorsal horn of the spinal column. Substance P may cause inflammation and edema, as well as pain. It may be associated with specific syndromes that produce pain for the client, including fibromyalgia or arthritis. 36. Which of the following is a fat-soluble vitamin? a. Vitamin C b. Vitamin D c. Vitamin B-6 d. Riboflavin ANSWER B: Fat-soluble vitamins are those that can be stored within the S - The Marketplace to Buy and Sell your Study Material body. If a person takes in more than necessary, excess amounts can be stored to be used for later. Although this may be beneficial to avoid vitamin deficiencies, fat-soluble vitamin toxicities may also occur. Fat-soluble vitamins are vitamins A, E, D, and K. 37. A nurse is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the nurse aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the nurse? a. Administer the feeding as ordered b. Pull the feeding tube out approximately 3 cm c. Flush the feeding tube with 60 cc of water d. Contact the physician ANSWER A: Checking the pH before administering an enteral feeding verifies placement that the gastrostomy tube is in the correct position. A pH of 4 or less indicates that the tube is in the stomach and the nurse may continue with the enteral feeding. 38. Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance? a. Perform nursing activities throughout the entire shift b. Assess for signs of increased muscle tone c. Minimize environmental noise d. Teach clients to perform the Valsalva maneuver S - The Marketplace to Buy and Sell your Study Material ANSWER C: When caring for a client who is at risk of activity intolerance, the nurse can diminish the impact of environmental stimuli by reducing noise. Environmental noise may require further energy from the client in order to manage his responses to stimuli. Reducing excess noise promotes rest and energy conservation. 39. A nurse is working with Mr. L, a client who is being seen for disrupted sleep patterns. The nurse encourages Mr. L to verbalize his feelings about sleep and his inability to maintain adequate sleep habits. What is the rationale for this action? a. Mr. L most likely has a mental illness that should be treated before his sleep issues b. Mr. L may have unrecognized anxiety or fear that could be contributing to poor sleep habits c. Mr. L may become tired once he starts talking d. None of the above ANSWER B: Some clients have difficulties with sleep due to unrecognized anxiety or fears. By encouraging clients to express their feelings and thoughts regarding sleep and sleep issues, the nurse allows the client the chance to work through negative feelings. By working out potential issues, the client may experience greater peace and relaxation, promoting sleep. 40. A nurse is preparing to attach a TENS unit to a client who is experiencing pain. Which of the following actions is most appropriate in this situation? a. Tell the client that he may experience tingling sensations