TEST BAK NCLEX
QUESTIONS 1-15
Ref # 4366
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal
bypass graft procedure. Which of the following assessments requires immediate notification of the
health care provider?
• Left foot is cool to the touch
• Absent lef t pedal pulse using Doppler analysis
• Inability to palpate the left pedal pulse
• Acute pain in the left lower leg
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left
lower leg are important findings, they all require additional nursing assessment prior to contacting the
health care provider. In clients without palpable pedal pulses, the next step in the assessment is to
perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis
requires immediately notifying the health care provider.
Ref # 1028
There's a new medication order that reads: "administer 1 gtt ciprofloxacin
solution OD Q 4 h" What action should the nurse take?
Call the prescriber to clarify and rewrite the order
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors.
"OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating
medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the
official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a
potentially dangerous "workaround." The nurse should call the health care provider who prescribed the
medication and clarify the order.
Ref # 1440
Which individual is at greatest risk for the development of hypertension?
45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the United
States. The incidence among the Hispanic population is rising.
Ref # 2446
A woman, who delivered five days ago and who had been diagnosed with
pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to
ask for advice. She states, "I have had the worst headache for the past two days.
It pounds and by the middle of the afternoon everything I look at looks wavy.
Nothing I have taken helps." What should the nurse do next?
Ask the client to stay on the line, get the address, and send an ambulance to the home
,The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to,
during, or after delivery; this may occur up to 10 days after delivery.
Ref # 2065
A client expresses anger when a call light is not answered within five minutes.
The client demanded a blanket. How should the nurse respond?
"I see this is frustrating for you. I have a few minutes so let's talk."
This is the best response because it gives credence to the client's feelings and then concerns. To say
"let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or
validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it
could have waited a few minutes is rude and non-accepting of the client's verbalized needs.
Ref # 2134
The client is admitted to an ambulatory surgery center and undergoes a right
inguinal orchiectomy. Which option is the priority before the client can be
discharged to home
Post-operative pain is managed
An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer
(testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with
an undescended testicle.) Due to the location of the incision, pain management is the priority. Most
men will be able to eat regularly when they get home; they should at least tolerate liquids before
discharge. It's important that the client is able to get up and walk with assistance, but this is not the
priority.
Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate
priority.
Ref # 1524
A nurse is teaching a group of adults about modifiable cardiac risk factors.
Which of the following should the nurse focus on first?
Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in
reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be
addressed at some point in time.
Ref # 1721
The clinic nurse is assisting with medical billing. The nurse uses the DRG
(Diagnosis Related Group) manual for which purpose?
Determine reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
Other insurance companies often use it as a standard for determining payment.
KEYWORDS DRG diagnosis related group
reimbursement
,Ref # 1328
A nurse is planning care for a 2 year-old hospitalized child. Which issue will
produce the most stress at this age? Separation anxiety While a toddler will experience all of
the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler
years.
Ref # 2319
The nurse is reviewing the laboratory results for several clients. Which of the
laboratory result indicates a client with partly compensated metabolic acidosis?
PaCO2 30 mm Hg
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea,
dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a
low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying
to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory
decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both
males and females. The chloride and sodium results are also WNL.
Ref # 2391
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA)
has died. Which type of precautions is appropriate to use when performing
postmortem care? Contact precautionsThe resistant bacteria remain alive for up to three days
after the client dies. Therefore, contact precautions must still be used. The body should also be labeled
as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves
are required.
Ref # 1436
A client has a chest tube inserted immediately after surgery for a left lower
lobectomy. During the repositioning of the client during the first postop check,
the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber
of the chest drain system. What is the appropriate nursing action?
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be
released into the chest drain when the client changes position this soon after surgery. The dark color of
the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be
expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If
the drainage exceeds 100 mL/hr, the nurse should call the surgeon.
Ref # 1623 A client is transported to the emergency department after a motor
vehicle accident. When assessing the client 30 minutes after admission, the nurse
notes several physical changes. Which finding would require the nurse's
immediate attention? Tracheal deviation
Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension
pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build,
collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to
the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency,
, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the
pressure.
Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would
expect the client to be treated with oral pancreatic enzymes and which type of
diet? High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to
prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for
osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten
intolerance, not CF, needs a gluten-free diet.
Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24
hours after surgical repair of a fractured femur. The child is crying and reports
having severe pain. The right foot is pale and there is no palpable pulse. What
action should the nurse take first? Notify the health care provider Pain and absence of a pulse
within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This
condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood
flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency.
Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.
Ref # 1927 The
nurse is examining a 2 year-old child with a tentative diagnosis of
Wilm's tumor. The nurse would be most concerned about which statement by
the mother? "Urinary output seems to be less over the past two days."
Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a
recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction.
Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate
intervention by the nurse.
Ref # 1370 A child is treated with succimer for lead poisoning. Which of these
assessments should the nurse perform first? Check complete blood count (CBC) with
differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning.
Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia.
Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ
Ref # 1773The client with a T-2 spinal cord injury reports having a "pounding"
headache. Further assessment by the nurse reveals excessive sweating, rash,
pilomotor erection, facial flushing, congested nasal passages and a heart rate of
50. What action should the nurse take next? Check the client for bladder distention and
the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia.
This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by
any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement,
fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The
QUESTIONS 1-15
Ref # 4366
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal
bypass graft procedure. Which of the following assessments requires immediate notification of the
health care provider?
• Left foot is cool to the touch
• Absent lef t pedal pulse using Doppler analysis
• Inability to palpate the left pedal pulse
• Acute pain in the left lower leg
Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left
lower leg are important findings, they all require additional nursing assessment prior to contacting the
health care provider. In clients without palpable pedal pulses, the next step in the assessment is to
perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis
requires immediately notifying the health care provider.
Ref # 1028
There's a new medication order that reads: "administer 1 gtt ciprofloxacin
solution OD Q 4 h" What action should the nurse take?
Call the prescriber to clarify and rewrite the order
Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors.
"OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating
medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the
official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a
potentially dangerous "workaround." The nurse should call the health care provider who prescribed the
medication and clarify the order.
Ref # 1440
Which individual is at greatest risk for the development of hypertension?
45 year-old African-American attorney
The incidence of hypertension is greater among African-Americans than other groups in the United
States. The incidence among the Hispanic population is rising.
Ref # 2446
A woman, who delivered five days ago and who had been diagnosed with
pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to
ask for advice. She states, "I have had the worst headache for the past two days.
It pounds and by the middle of the afternoon everything I look at looks wavy.
Nothing I have taken helps." What should the nurse do next?
Ask the client to stay on the line, get the address, and send an ambulance to the home
,The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for
evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to,
during, or after delivery; this may occur up to 10 days after delivery.
Ref # 2065
A client expresses anger when a call light is not answered within five minutes.
The client demanded a blanket. How should the nurse respond?
"I see this is frustrating for you. I have a few minutes so let's talk."
This is the best response because it gives credence to the client's feelings and then concerns. To say
"let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or
validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it
could have waited a few minutes is rude and non-accepting of the client's verbalized needs.
Ref # 2134
The client is admitted to an ambulatory surgery center and undergoes a right
inguinal orchiectomy. Which option is the priority before the client can be
discharged to home
Post-operative pain is managed
An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer
(testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with
an undescended testicle.) Due to the location of the incision, pain management is the priority. Most
men will be able to eat regularly when they get home; they should at least tolerate liquids before
discharge. It's important that the client is able to get up and walk with assistance, but this is not the
priority.
Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate
priority.
Ref # 1524
A nurse is teaching a group of adults about modifiable cardiac risk factors.
Which of the following should the nurse focus on first?
Smoking cessation
Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in
reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be
addressed at some point in time.
Ref # 1721
The clinic nurse is assisting with medical billing. The nurse uses the DRG
(Diagnosis Related Group) manual for which purpose?
Determine reimbursement for a medical diagnosis
DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
Other insurance companies often use it as a standard for determining payment.
KEYWORDS DRG diagnosis related group
reimbursement
,Ref # 1328
A nurse is planning care for a 2 year-old hospitalized child. Which issue will
produce the most stress at this age? Separation anxiety While a toddler will experience all of
the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler
years.
Ref # 2319
The nurse is reviewing the laboratory results for several clients. Which of the
laboratory result indicates a client with partly compensated metabolic acidosis?
PaCO2 30 mm Hg
Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea,
dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a
low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying
to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory
decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both
males and females. The chloride and sodium results are also WNL.
Ref # 2391
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA)
has died. Which type of precautions is appropriate to use when performing
postmortem care? Contact precautionsThe resistant bacteria remain alive for up to three days
after the client dies. Therefore, contact precautions must still be used. The body should also be labeled
as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves
are required.
Ref # 1436
A client has a chest tube inserted immediately after surgery for a left lower
lobectomy. During the repositioning of the client during the first postop check,
the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber
of the chest drain system. What is the appropriate nursing action?
Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be
released into the chest drain when the client changes position this soon after surgery. The dark color of
the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be
expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If
the drainage exceeds 100 mL/hr, the nurse should call the surgeon.
Ref # 1623 A client is transported to the emergency department after a motor
vehicle accident. When assessing the client 30 minutes after admission, the nurse
notes several physical changes. Which finding would require the nurse's
immediate attention? Tracheal deviation
Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension
pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build,
collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to
the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency,
, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the
pressure.
Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would
expect the client to be treated with oral pancreatic enzymes and which type of
diet? High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices.
Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to
prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for
osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten
intolerance, not CF, needs a gluten-free diet.
Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24
hours after surgical repair of a fractured femur. The child is crying and reports
having severe pain. The right foot is pale and there is no palpable pulse. What
action should the nurse take first? Notify the health care provider Pain and absence of a pulse
within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This
condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood
flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency.
Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity.
Ref # 1927 The
nurse is examining a 2 year-old child with a tentative diagnosis of
Wilm's tumor. The nurse would be most concerned about which statement by
the mother? "Urinary output seems to be less over the past two days."
Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a
recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction.
Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate
intervention by the nurse.
Ref # 1370 A child is treated with succimer for lead poisoning. Which of these
assessments should the nurse perform first? Check complete blood count (CBC) with
differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning.
Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia.
Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ
Ref # 1773The client with a T-2 spinal cord injury reports having a "pounding"
headache. Further assessment by the nurse reveals excessive sweating, rash,
pilomotor erection, facial flushing, congested nasal passages and a heart rate of
50. What action should the nurse take next? Check the client for bladder distention and
the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia.
This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by
any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement,
fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The
