NURSING 21 NCLEX-RN EXAM TEST BANK
RATIONALE
1001
Which electrolyte abnormalities would the nurse expect to occur while working with a client
who just sustained partial- and full-thickness burns?
1) Decreased sodium and increased potassium
2) Increased calcium and decreased potassium
3) Decreased magnesium and increased sodium
4) Increased sodium and decreased potassium
CORRECT ANSWER: 1
RATIONALE: Sodium levels decrease and potassium levels increase secondary to massive
fluid shifts into the interstitium and release of potassium from cells that are destroyed. The other
responses are incorrect.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Analysis
CONTENT AREA: Adult Health: Integumentary
STRATEGY: Associate high potassium levels with cell destruction and make sure both items in
the option are correct.
1002
The nurse provides teaching to a client after the removal of a short leg cast. The nurse should
include which of the following in discussions with the client?
1) Wash the skin with undiluted hydrogen peroxide.
2) Vigorously scrub the legs to remove dead skin.
3) Gently wash and lubricate the leg.
4) Avoid touching the leg for 2 weeks.
CORRECT ANSWER: 3
RATIONALE: Dead skin and exudates often collect under the cast, and efforts to remove it
should be done gradually. The client should be instructed to avoid any vigorous scrubbing of the
skin to avoid breaks, which increase the risk for infection. The use of undiluted peroxide is too
harsh for the skin. There is no reason why the leg cannot be touched after removal of the cast.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Implementation
, CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of skin care following cast
removal. Use nursing knowledge and the process of elimination to make a selection.
1003
Which of the following nursing diagnoses would be the priority for a client with Paget’s
disease?
1) Risk for noncompliance
2) Disturbed sleep pattern
3) Impaired physical mobility
4) Disturbed body image
CORRECT ANSWER: 3
RATIONALE: Impaired physical mobility is the appropriate priority nursing diagnosis for a
client with Paget’s disease. The client needs to remain active to decrease the complications
associated with immobility and to maintain the ability to perform self-care activities. The other
diagnoses, although appropriate, are not the priority in clients with Paget’s disease.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Planning
CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of priorities for the client with
Paget’s disease. Use nursing knowledge and the process of elimination to make a selection.
1004
A client with a right arm cast for fractured humerus states, “I haven’t been able to extend the
fingers on my right hand since this morning.” What action should the nurse take next?
1) Assess neurovascular status.
2) Ask the client to massage the fingers.
3) Encourage the client to take the prescribed analgesics as ordered.
4) Elevate the right arm on a pillow to reduce edema.
CORRECT ANSWER: 1
RATIONALE: This symptom suggests neurological injury caused by pressure on nerves and
soft tissue because of swelling. Other symptoms of neurovascular compromise should be
assessed and reported to the physician.
COGNITIVE LEVEL: Analysis
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Implementation
CONTENT AREA: Adult Health: Musculoskeletal
, STRATEGY: The core issue of the question is the knowledge of priority assessments in a client
with possible compartment syndrome. Use nursing knowledge and the process of elimination to
make a selection.
1005
A client with an open fracture is at risk for developing osteomyelitis. Which of the following
classic symptoms would the nurse assess for to detect development of this complication?
1) Low bone density
2) Elevated temperature
3) Acute respiratory distress
4) Shortening of the affected extremity
CORRECT ANSWER: 2
RATIONALE: Elevated temperature is a classic symptom seen with this osteomyelitis as a
systemic response to the invading organism. Pain, swelling, and tenderness may also accompany
the fever. Acute respiratory distress (option 3) is more suggestive of embolism but not infection.
The extremity does not shorten.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Assessment
CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of manifestations of
osteomyelitis. Use nursing knowledge and the process of elimination to make a selection.
1006
An obese client with degenerative joint disease is being managed pharmacologically with
aspirin therapy. The nurse knows that additional client teaching is necessary when the client
makes which of the following statements?
1) “I take my aspirin only when I have extreme pain and stiffness.”
2) “I use heat sometimes to help decrease my pain and joint stiffness.”
3) “I frequently examine my stools for bleeding.”
4) “I started an exercise program to lose weight.”
CORRECT ANSWER: 1
RATIONALE: Aspirin therapy for this condition is continuous and is effective only after a
therapeutic level is reached. It should not be taken intermittently (option 1). The other options are
correct statements about self-care measures when taking aspirin for degenerative joint disease.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Evaluation
, CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of appropriate self-management
techniques for degenerative joint disease. Use nursing knowledge and the process of elimination
to make a selection.
1007
A client underwent a lumbar laminectomy today. Which nursing diagnosis has highest priority
for this client?
1) Disturbed body image disturbance
2) Social isolation
3) Ineffective role performance
4) Impaired physical mobility
CORRECT ANSWER: 4
RATIONALE: Immediately after surgery, the client will be inclined not to move because of
pain and fear of disturbing the operative site. Minimal scarring results from this surgery, so body
image disturbance is not likely to be appropriate (option 1). The psychosocial diagnoses in
options 2 and 3 have less priority than option 4 because option 4 is a physiological concern.
COGNITIVE LEVEL: Analysis
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Analysis
CONTENT AREA: Fundamentals
STRATEGY: The core issue of the question is the knowledge of priority nursing diagnoses
following musculoskeletal surgery. Use nursing knowledge and the process of elimination to
make a selection.
1008
A client had a left above-the-knee amputation today. For the first 24 hours postoperatively, the
nurse makes it a priority to do which of the following to properly manage the surgical site?
1) Elevate the residual limb on a pillow.
2) Loosen the stump dressing every 4 hours.
3) Maintain the residual limb in a dependent position.
4) Change dressings as often as needed.
CORRECT ANSWER: 1
RATIONALE: Elevating the limb on a pillow facilitates venous return, decreases swelling, and
promotes comfort. The stump dressing is usually a compression type to mold the stump and to
decrease the edema associated with inflammation, so option 2 is an inappropriate intervention.
The other options are also inappropriate because option 3 increases risk of edema and option 4 is
done as ordered.
RATIONALE
1001
Which electrolyte abnormalities would the nurse expect to occur while working with a client
who just sustained partial- and full-thickness burns?
1) Decreased sodium and increased potassium
2) Increased calcium and decreased potassium
3) Decreased magnesium and increased sodium
4) Increased sodium and decreased potassium
CORRECT ANSWER: 1
RATIONALE: Sodium levels decrease and potassium levels increase secondary to massive
fluid shifts into the interstitium and release of potassium from cells that are destroyed. The other
responses are incorrect.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Analysis
CONTENT AREA: Adult Health: Integumentary
STRATEGY: Associate high potassium levels with cell destruction and make sure both items in
the option are correct.
1002
The nurse provides teaching to a client after the removal of a short leg cast. The nurse should
include which of the following in discussions with the client?
1) Wash the skin with undiluted hydrogen peroxide.
2) Vigorously scrub the legs to remove dead skin.
3) Gently wash and lubricate the leg.
4) Avoid touching the leg for 2 weeks.
CORRECT ANSWER: 3
RATIONALE: Dead skin and exudates often collect under the cast, and efforts to remove it
should be done gradually. The client should be instructed to avoid any vigorous scrubbing of the
skin to avoid breaks, which increase the risk for infection. The use of undiluted peroxide is too
harsh for the skin. There is no reason why the leg cannot be touched after removal of the cast.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Implementation
, CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of skin care following cast
removal. Use nursing knowledge and the process of elimination to make a selection.
1003
Which of the following nursing diagnoses would be the priority for a client with Paget’s
disease?
1) Risk for noncompliance
2) Disturbed sleep pattern
3) Impaired physical mobility
4) Disturbed body image
CORRECT ANSWER: 3
RATIONALE: Impaired physical mobility is the appropriate priority nursing diagnosis for a
client with Paget’s disease. The client needs to remain active to decrease the complications
associated with immobility and to maintain the ability to perform self-care activities. The other
diagnoses, although appropriate, are not the priority in clients with Paget’s disease.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Planning
CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of priorities for the client with
Paget’s disease. Use nursing knowledge and the process of elimination to make a selection.
1004
A client with a right arm cast for fractured humerus states, “I haven’t been able to extend the
fingers on my right hand since this morning.” What action should the nurse take next?
1) Assess neurovascular status.
2) Ask the client to massage the fingers.
3) Encourage the client to take the prescribed analgesics as ordered.
4) Elevate the right arm on a pillow to reduce edema.
CORRECT ANSWER: 1
RATIONALE: This symptom suggests neurological injury caused by pressure on nerves and
soft tissue because of swelling. Other symptoms of neurovascular compromise should be
assessed and reported to the physician.
COGNITIVE LEVEL: Analysis
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Implementation
CONTENT AREA: Adult Health: Musculoskeletal
, STRATEGY: The core issue of the question is the knowledge of priority assessments in a client
with possible compartment syndrome. Use nursing knowledge and the process of elimination to
make a selection.
1005
A client with an open fracture is at risk for developing osteomyelitis. Which of the following
classic symptoms would the nurse assess for to detect development of this complication?
1) Low bone density
2) Elevated temperature
3) Acute respiratory distress
4) Shortening of the affected extremity
CORRECT ANSWER: 2
RATIONALE: Elevated temperature is a classic symptom seen with this osteomyelitis as a
systemic response to the invading organism. Pain, swelling, and tenderness may also accompany
the fever. Acute respiratory distress (option 3) is more suggestive of embolism but not infection.
The extremity does not shorten.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Assessment
CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of manifestations of
osteomyelitis. Use nursing knowledge and the process of elimination to make a selection.
1006
An obese client with degenerative joint disease is being managed pharmacologically with
aspirin therapy. The nurse knows that additional client teaching is necessary when the client
makes which of the following statements?
1) “I take my aspirin only when I have extreme pain and stiffness.”
2) “I use heat sometimes to help decrease my pain and joint stiffness.”
3) “I frequently examine my stools for bleeding.”
4) “I started an exercise program to lose weight.”
CORRECT ANSWER: 1
RATIONALE: Aspirin therapy for this condition is continuous and is effective only after a
therapeutic level is reached. It should not be taken intermittently (option 1). The other options are
correct statements about self-care measures when taking aspirin for degenerative joint disease.
COGNITIVE LEVEL: Application
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Evaluation
, CONTENT AREA: Adult Health: Musculoskeletal
STRATEGY: The core issue of the question is the knowledge of appropriate self-management
techniques for degenerative joint disease. Use nursing knowledge and the process of elimination
to make a selection.
1007
A client underwent a lumbar laminectomy today. Which nursing diagnosis has highest priority
for this client?
1) Disturbed body image disturbance
2) Social isolation
3) Ineffective role performance
4) Impaired physical mobility
CORRECT ANSWER: 4
RATIONALE: Immediately after surgery, the client will be inclined not to move because of
pain and fear of disturbing the operative site. Minimal scarring results from this surgery, so body
image disturbance is not likely to be appropriate (option 1). The psychosocial diagnoses in
options 2 and 3 have less priority than option 4 because option 4 is a physiological concern.
COGNITIVE LEVEL: Analysis
CLIENT NEED: Physiological Integrity: Physiological Adaptation
INTEGRATED PROCESS: Nursing Process: Analysis
CONTENT AREA: Fundamentals
STRATEGY: The core issue of the question is the knowledge of priority nursing diagnoses
following musculoskeletal surgery. Use nursing knowledge and the process of elimination to
make a selection.
1008
A client had a left above-the-knee amputation today. For the first 24 hours postoperatively, the
nurse makes it a priority to do which of the following to properly manage the surgical site?
1) Elevate the residual limb on a pillow.
2) Loosen the stump dressing every 4 hours.
3) Maintain the residual limb in a dependent position.
4) Change dressings as often as needed.
CORRECT ANSWER: 1
RATIONALE: Elevating the limb on a pillow facilitates venous return, decreases swelling, and
promotes comfort. The stump dressing is usually a compression type to mold the stump and to
decrease the edema associated with inflammation, so option 2 is an inappropriate intervention.
The other options are also inappropriate because option 3 increases risk of edema and option 4 is
done as ordered.
