NCLEX Pre exam study guide
1. A female client with bulimia nervosa reports that her major problem is eating too much food in
a short period of time and then vomiting. Which short-term goal is the most important?
Determine the amount of food the client will eat without purging
Explanation:
This client must meet her nutritional needs to prevent further complications. She must identify the
amount of food she can eat without purging as her first short-term goal. Binge eaters cannot recognize
their satiety level or their feelings of fullness. Obtaining knowledge, or verbalizing her fears and feelings
about food are not priority goals for this client. After meeting immediate physiologic needs, therapy is
an important of treatment for this disorder.
2. The nurse is providing discharge instructions for the parents of an infant who has recently
undergone cardiac surgery. The nurse determines that teaching was effective when the parents
make which statements? Select all that apply.
- "I should keep giving my baby all prescribed medicines until the health care provider tells me to stop."
- "I should wait about six weeks to schedule an appointment for my baby to get her immunizations."
Explanation:
Drugs, such as digoxin and furosemide, shouldn't be stopped abruptly. There are no dietary restrictions.
Parents are encouraged to keep their child away from crowds for the first few weeks after surgery in
order to prevent exposure to infections such as colds or respiratory syncytial virus bronchiolitis.
Immunizations should be delayed for at least six weeks following surgery.
3. A scrub nurse is assigned to the operating room for an appendectomy case. Which action by the
scrub nurse violates the standards of sterility during the operation?
Tying the back of another nurse's gown.
,Explanation:
Scrub nurses, also called perioperative nurses, are registered nurses who assist in surgical procedures by
setting up the room before the operation, working with the doctor during surgery, and preparing the
patient for the move to the recovery room. The scrub nurse must remain sterile during the operation as
a primary responsibility is assisting the surgeon with surgical equipment. Touching the back of a
nonsterile gown breaks sterility. All of the other measures maintain sterility.
4. A client with a history of pheochromocytoma is admitted to the hospital in an acute
hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, the nurse
expects to administer:
phentolamine.
Explanation:
Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural
catecholamines that raise the blood pressure. Phentolamine, an alpha-adrenergic given by I.V. bolus or
drip, antagonizes the body's response to circulating epinephrine and norepinephrine, reducing blood
pressure quickly and effectively. Although methyldopa is an antihypertensive agent available in
parenteral form, it is not effective in treating hypertensive emergencies. Mannitol, a diuretic, is not used
to treat hypertensive emergencies. Felodipine, an antihypertensive agent, is available only in extended-
release tablets and therefore, does not reduce blood pressure quickly enough to correct hypertensive
crisis.
5. The development of disaster plans should take into consideration that children are more
susceptible to the effects of a chemical attack than adults because children:
have thinner skin than adults.
Explanation:
, Children are more susceptible to the effects of chemical and biological attacks because they have
thinner skin than adults, increasing their risk of absorbing a chemical. They also have a larger, not
smaller, body surface area in relation to their weight than do adults, which increases the chance of
chemical absorption. Children breathe at a faster, not slower, rate than adults, allowing them to inhale
greater amounts of a toxic agent. Additionally, some chemical agents are heavier than air and
accumulate close to the ground, which is closer to a child's breathing zone than an adult's. Because they
have less fluid reserve than adults, children are at greater risk of developing rapid dehydration from
agents that cause vomiting or diarrhea.
6. A nurse is caring for a client of African descent. Among the following, who should the nurse use
as a key informant?
Church mothers.
The nurse should use church mothers as key informants for the client. Voodoo priests are key
informants for Haitians. For Mexicans and Roman Catholics, the curandera can serve as key informant.
Spiritist healers are key informants for Puerto Ricans.
7. A client with Cushing's disease tells the nurse that the health care provider (HCP) said the
morning serum cortisol level was within normal limits. The client asks, "How can that be? I am
not imagining all these symptoms!" The nurse's response will be based on the fact that?
The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal
secretion pattern.
Explanation:
Cushing's disease is commonly caused by loss of the diurnal cortisol secretion pattern. The client's
random morning cortisol level may be within normal limits, but secretion continues at that level
throughout the entire day. Cortisol levels should normally decrease after the morning peak. Analysis of a
24-hour urine specimen is often useful in identifying the cumulative excess. Clients will not have
symptoms with normal cortisol levels. Hormones are present in the blood.
1. A female client with bulimia nervosa reports that her major problem is eating too much food in
a short period of time and then vomiting. Which short-term goal is the most important?
Determine the amount of food the client will eat without purging
Explanation:
This client must meet her nutritional needs to prevent further complications. She must identify the
amount of food she can eat without purging as her first short-term goal. Binge eaters cannot recognize
their satiety level or their feelings of fullness. Obtaining knowledge, or verbalizing her fears and feelings
about food are not priority goals for this client. After meeting immediate physiologic needs, therapy is
an important of treatment for this disorder.
2. The nurse is providing discharge instructions for the parents of an infant who has recently
undergone cardiac surgery. The nurse determines that teaching was effective when the parents
make which statements? Select all that apply.
- "I should keep giving my baby all prescribed medicines until the health care provider tells me to stop."
- "I should wait about six weeks to schedule an appointment for my baby to get her immunizations."
Explanation:
Drugs, such as digoxin and furosemide, shouldn't be stopped abruptly. There are no dietary restrictions.
Parents are encouraged to keep their child away from crowds for the first few weeks after surgery in
order to prevent exposure to infections such as colds or respiratory syncytial virus bronchiolitis.
Immunizations should be delayed for at least six weeks following surgery.
3. A scrub nurse is assigned to the operating room for an appendectomy case. Which action by the
scrub nurse violates the standards of sterility during the operation?
Tying the back of another nurse's gown.
,Explanation:
Scrub nurses, also called perioperative nurses, are registered nurses who assist in surgical procedures by
setting up the room before the operation, working with the doctor during surgery, and preparing the
patient for the move to the recovery room. The scrub nurse must remain sterile during the operation as
a primary responsibility is assisting the surgeon with surgical equipment. Touching the back of a
nonsterile gown breaks sterility. All of the other measures maintain sterility.
4. A client with a history of pheochromocytoma is admitted to the hospital in an acute
hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, the nurse
expects to administer:
phentolamine.
Explanation:
Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural
catecholamines that raise the blood pressure. Phentolamine, an alpha-adrenergic given by I.V. bolus or
drip, antagonizes the body's response to circulating epinephrine and norepinephrine, reducing blood
pressure quickly and effectively. Although methyldopa is an antihypertensive agent available in
parenteral form, it is not effective in treating hypertensive emergencies. Mannitol, a diuretic, is not used
to treat hypertensive emergencies. Felodipine, an antihypertensive agent, is available only in extended-
release tablets and therefore, does not reduce blood pressure quickly enough to correct hypertensive
crisis.
5. The development of disaster plans should take into consideration that children are more
susceptible to the effects of a chemical attack than adults because children:
have thinner skin than adults.
Explanation:
, Children are more susceptible to the effects of chemical and biological attacks because they have
thinner skin than adults, increasing their risk of absorbing a chemical. They also have a larger, not
smaller, body surface area in relation to their weight than do adults, which increases the chance of
chemical absorption. Children breathe at a faster, not slower, rate than adults, allowing them to inhale
greater amounts of a toxic agent. Additionally, some chemical agents are heavier than air and
accumulate close to the ground, which is closer to a child's breathing zone than an adult's. Because they
have less fluid reserve than adults, children are at greater risk of developing rapid dehydration from
agents that cause vomiting or diarrhea.
6. A nurse is caring for a client of African descent. Among the following, who should the nurse use
as a key informant?
Church mothers.
The nurse should use church mothers as key informants for the client. Voodoo priests are key
informants for Haitians. For Mexicans and Roman Catholics, the curandera can serve as key informant.
Spiritist healers are key informants for Puerto Ricans.
7. A client with Cushing's disease tells the nurse that the health care provider (HCP) said the
morning serum cortisol level was within normal limits. The client asks, "How can that be? I am
not imagining all these symptoms!" The nurse's response will be based on the fact that?
The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal
secretion pattern.
Explanation:
Cushing's disease is commonly caused by loss of the diurnal cortisol secretion pattern. The client's
random morning cortisol level may be within normal limits, but secretion continues at that level
throughout the entire day. Cortisol levels should normally decrease after the morning peak. Analysis of a
24-hour urine specimen is often useful in identifying the cumulative excess. Clients will not have
symptoms with normal cortisol levels. Hormones are present in the blood.
