NCLEX practice exam 1 and rationales

NCLEX practice exam 1 and rationales The nurse is caring for a client for removal of the pituitary gland. The nurse should be particularly of: a) Nasal Congestion b) Abdominal Tenderness c) Muscle Tetany d) Olig ...

NCLEX practice exam 1 and rationales The nurse is caring for a client for removal of the pituitary gland. The nurse should be particularly of: a) Nasal Congestion b) Abdominal Tenderness c) Muscle Tetany d) Oliguria Correct Answer: A - Nasal Congestion Removal of the pituitary gland is usually done by a transphenoidal approach, through the nose. Nasal congestion further interferes with the airway. Answers B, C, and D are not correct because they are not directly associated with the pituitary gland A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136 and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? a) Hypernatremia b) Hypokalemia c) Myelosuppression d) Leukosytosis Correct Answer: B - Hypokalemia Hypokalemia is evident from the lab values listed. the other laboratory findings are within normal limits, making A, C, and D incorrect A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibilty of the nurse? a) taking the vital signs b) obtaining the permit c) explaining the procedure d) checking the lab work Correct Answer: A - taking the vital signs The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor. The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face and neck. Which action should receive priority? a) Starting an IV b) Applying oxygen c) Obtaining blood gasses d) Medicating the patient for pain Correct Answer: B- Applying oxygen The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D is ordered by the doctor The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the patient? a) rest in bed after taking the medication for at least 30 minutes b) avoid rapid movements after taking the medication c) take the medication with water only d) allow at least one hour between taking the medication and taking other medications Correct Answer: C - take the medication with water only Fosamax should be taken with water only. the client should also remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax. The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? a) a pair of forceps b) a torque wrench c) a pair of wire cutters d) a screwdriver Correct Answer: B- a torque wrench A torque wrench is kept at the bedside table to tighten and loosen the screws of crutchfield tongs. The wrench control the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver would not be used. An infant weighs 7 pounds at birth. The expected weight by one year should be: a) 10 pounds b) 12 pounds c) 18 pounds d) 21 pounds Correct Answer: D - 21 pounds The birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location? a) hemiplegia b) aphasia c) nausea d) bone pain Correct Answer: D - bone pain Sarcoma is a type of bone cancer; therefore, bone pain would be expected. Answers A, B, and C are not specific to this type of cancer. The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? a) uric acid of 5 mg/dL b) hematocrit of 33% c) WBC 2,000 per cubic millimeter d) platelets 150,000 per cubic millimeter Correct Answer: C - 2,000 per cubic millimeter Tegretol can suppress the none marrow and decrease the white blood cell count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug. Answers A and D are within normal limits, and Answer B is a lower limit of normal. A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? a) "Tell me about his pain." b) "What does his vomit look like?" c) "Describe his usual diet." d) "Have you noticed changes in his abdominal size?" Correct Answer: C - "Describe his usual diet." The least helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? a) bran b) fresh peaches c) cucumber salad d) yeast rolls Correct Answer: C - cucumber salad The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact bran cereal and fruit will help prevent constipation A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? a) teaching how to irrigate the illeostomy b) stopping electrolyte loss in the incisional area c) encouraging a high-fiber diet d) facilitating perineal wound drainage Correct Answer: D - facilitating perineal wound drainage The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in answer A; he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect. A high-fiber diet, in answer C, is not ordered at this time. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on low-roughage diet. Which food would have to be eliminated from this client's diet? a) roasted chicken b) noodles c) cooked broccoli d) custard Correct Answer: C - cooked broccoli The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: a) the baby is dehydrated due to polyuria b) the baby is hypoglycemic due to lack of glucose c) the baby is allergic to the formula the mother is giving him d) the baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast- feeding Correct Answer: D - the baby can lose up to 10% of weight due to meconium, loss of extra cellular fluid, and the initiation of breast-feeding After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia. or allergy to the infant formula; thus answers A, B, and C are incorrect The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for diagnosis? a) Foul breath b) Dysphagia c) Diarrhea