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NCLEX-PN Test-Bank
(200 Questions with
Answers and
Explanation)
1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for: A. Nasal congestion B. Abdominal tenderness C. Muscle tetany D. Oliguria Answer A: Removal of the pituitary gland is usually done by a transsphenoidal 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. 2. 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. Hypernatre mia B. Hypokalemia C. Myelosuppression D. Leukocytosis Answer B: Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits, making answers A, C, and D incorrect.
3. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. Taking the vital signs B. Obtaining the permit C. Explaining the procedure D. Checking the lab work Answer A: 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 and, therefore, are incorrect for this question. 4. 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 gases D. Medicating the client for pain
6. The nurse is making initial rounds on a client with a C 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 Answer B: A torque wrench is kept at the bedside to tighten and loosen the screws of crutchfield tongs. This wrench controls the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver, in answers A, C, and D, would not be used and, thus, are incorrect. 7. An infant weighs 7 pounds at birth. The expected weight by 1 year should be: A. 10 pounds B. 12 pounds C. 18 pounds D. 21 pounds Answer D: A birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. Answers A, B, and C therefore are incorrect. 8. 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 Answer D: 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 and are incorrect.
A. Bran B. Fresh peaches C. Cucumber salad D. Yeast rolls
Answer C: 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.
12. 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 Answer D: 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. 13. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a 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 Answer C: The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in answers A, B, and D are allowed.
D. The baby can lose up to 10% of weight due to meconium stool, loss of B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. extracellular fluid, and initiation of breast-feeding. Answer D: 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.
15. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphag ia C. Diarrhea D. Chronic hiccups Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings. 16. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage Answer A: The client with a lung resection will have chest tubes and a drainage- collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion,
vibration, or drainage. Therefore, answers B, C, and D are incorrect.
airplane.
19. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block Answer A: Suctioning can cause a vagal response and bradycardia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely. 20. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client’s level of anxiety B. Evaluation of the client’s exercise tolerance C. Identification of peripheral pulses D. Assessment of bowel sounds and activity Answer C: The assessment that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A. 21. A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in
D. “You will not be able to drink fluids for 24 hours before the study.” Answer B: Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.
22. The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks B. Complaints of numbness and tingling in the extremities C. A red, beefy tongue D. A hemoglobin level of 12.0gm/dL Answer C: A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal. 23. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Buck’s traction
D. An abduction pillow Answer C: The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered
Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.
26. A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4×4s B. Cover the wound with a sterile 4×4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound Answer C: If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case. 27. The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye Answer B: It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect. 28. The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in
