Tuesday, September 23, 2008

Sample NCLEX questions with rationale

PAIN

1. A chronic pain client reports to you, the charge nurse, that the nurse have not been responding to requests for pain medication. What is your initial action?

a. Check the MARs and nurses’ notes for the past several days.

b. Ask the nurse educator to give an in-service about pain management.

c. Perform a complete pain assessment and history on the client.

d. Have a conference with the nurses responsible for the care of this client


2. Family members are encouraging your client to “tough it out” rather than run the risk of becoming addicted to narcotics. The client is stoically abiding by the family’s wishes. Priority nursing interventions for this client should target which dimension of pain?

a. Sensory

b. Affective

c. Sociocultural

d. Behavioral

e. Cognitive


3. A client with diabetic neuropathy reports a burning, electrical-type in the lower extremities that is not responding to NSAIDs. You anticipate that the physician will order which adjuvant medication for this type of pain?

a. Amitriptyline (Elavil)

b. Corticosteroids

c. Methylphenidate (Ritalin)

d. Lorazepam (Ativan)


4. Which client is most likely to receive opioids for extended periods of time?

a. A client with fibrolyalgia

b. A client with phantom limb pain

c. A client with progressive pancreatic cancer

d. A client with trigeminal neuralgia


5. As the charge nurse, you are reviewing the charts of clients who were assigned to a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?

a. Make a note in the nurse’s file and continue to observe clinical performance

b. Refer the new nurse to the in-service education department.

c. Quiz the nurse about knowledge of pain management

d. Give praise for the correct dose and time and discuss the deficits in charting.


6. In caring for a young child with pain, which assessment tool is the most useful?

a. Simple description pain intensity scale

b. 0-10 numeric pain scale

c. Faces pain-rating scale

d. McGill-Melzack pain questionnaire


7. In applying the principles of pain treatment, what is the first consideration?

a. Treatment is based on client goals.

b. A multidisciplinary approach is needed.

c. The client must be believed about perceptions of own pain.

d. Drug side effects must be prevented and managed.


8. Which route of administration is preferred if immediate analgesia and rapid titration are necessary?

a. Intraspinal

b. Patient-controlled analgesia (PCA)

c. Intravenous (IV)

d. Sublingual


9. When titrating an analgesic to manage pain, what is the priority goal?

a. Administer smallest dose that provides relief with the fewest side effects.

b. Titrate upward until the client is pain free.

c. Titrate downwards to prevent toxicity.

d. Ensure that the drug is adequate to meet the client’s subjective needs.


10. In educating clients about non-pharmaceutical alternatives, which topic could you delegate to an experienced LPN/LVN, who will function under your continued support and supervision?

a. Therapeutic touch

b. Use of heat and cold applications

c. Meditation

d. Transcutaneous electrical nerve stimulation (TENS)


11. Place the examples of drugs in the order of usage according to the World Health Organization (WHO) analgesic ladder.

a. Morphine, hydromorphone, acetaminophen and lorazepam

b. NSAIDs and corticosteroids

c. Codeine, oxycodone and diphenhydramine

_____, _____, _____


12. Which client is at greater risk for respiratory depression while receiving opioids for analgesia?

a. An elderly chronic pain client with a hip fracture

b. A client with a heroin addiction and back pain

c. A young female client with advanced multiple myeloma

d. A child with an arm fracture and cystic fibrosis


13. A client appears upset and tearful, but denies pain and refuses pain medication, because “my sibling is a drug addict and has ruined out lives.” What is the priority intervention for this client?

a. Encourage expression of fears on past experiences

b. Provide accurate information about use of pain medication

c. Explain that addiction is unlikely among acute care clients.

d. Seek family assistance in resolving this problem.


14. A client is being tapered off opioids and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal?

a. Fever

b. Nausea

c. Diaphoresis

d. Abdominal cramps


15. In caring for clients with pain and discomfort, which task is most appropriate to delegate to the nursing assistant?

a. Assist the client with preparation of a sitz bath.

b. Monitor the client for signs of discomfort while ambulating

c. Coach the client to deep breathe during painful procedures

d. Evaluate relief after applying a cold application.


16. The physician has ordered a placebo for a chronic pain client. You are newly hired nurse and you feel very uncomfortable administering the medication. What is the first action that you should take?

a. Prepare the medication and hand it to the physician

b. Check the hospital policy regarding use of the placebo.

c. Follow a personal code of ethics and refuse to give it.

d. Contact the charge nurse for advice.


17. For a cognitively impaired client who cannot accurately report pain, what is the first action that you should take?

a. Closely assess for nonverbal signs such as grimacing or rocking.

b. Obtain baseline behavioral indicators from family members.

c. Look at the MAR and chart, to note the time of the last dose and response.

d. Give the maximum PRS dose within the minimum time frame for relief.


18. Which route of administration is preferable for administration of daily analgesics (if all body systems are functional)?

a. IV

b. IM or subcutaneous

c. Oral

d. Transdermal

e. PCA


19. A first day post-operative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take?

a. Deliver the bolus dose per standing order.

b. Contact the physician to increase the dose.

c. Try non-pharmacological comfort measures.

d. Assess the pain for location, quality, and intensity.


20. Which non-pharmacological measure is particularly useful for a client with acute pancreatitis?

a. Diversional therapy, such as playing cards or board games

b. Massage of back and neck with warmed lotion

c. Side-lying position with knees to chest and pillow against abdomen

d. Transcutaneous electrical nerve stimulation (TENS)


21. What is the best way to schedule medication for a client with constant pain?

a. PRN at the client’s request

b. Prior to painful procedures

c. IV bolus after pain assessment

d. Around-the-clock


22. Which client(s) are appropriate to assign to the LPN/LVN, who will function under the supervision of the RN or team leader? (Choose all that apply.)

a. A client who needs pre-op teaching for use of a PCA pump

b. A client with a leg cast who needs neurologic checks and PRN hydrocodone

c. A client post-op toe amputation with diabetic neuropathic pain

d. A client with terminal cancer and severe pain who is refusing medication


23. For a client who is taking aspirin, which laboratory value should be reported to the physician?

a. Potassium 3.6 mEq/L

b. Hematocrit 41%

c. PT 14 seconds

d. BUN 20 mg/dL


24. Which client(s) would be appropriate to assign to a newly graduated RN, who has recently completed orientation? (Choose all that apply.)

a. An anxious, chronic pain client who frequently uses the call button

b. A client second day post-op who needs pain medication prior to dressing changes

c. A client with HIV who reports headache and abdominal and pleuritic chest pain

d. A client who is being discharged with a surgically implanted catheter


25. A family member asks you, “Why can’t you give more medicine? He is still having a lot of pain.” What is your best response?

a. “The doctor ordered the medicine to be given every 4 hours.”

b. “If the medication is given too frequently he could suffer ill effects.”

c. “Please tell him that I will be right there to check of him.”

d. “Let’s wait about 30-40 minutes. If there is no relief I’ll call the doctor.”

CANCER


26. You are caring for a patient with esophageal cancer. Which task could be delegated to the nursing assistant?

a. Assist the patient with oral hygiene.

b. Observe the patient’s response to feedings.

c. Facilitate expression of grief or anxiety.

d. Initiate daily weights.


27. A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?

a. Diarrhea/Constipation related to altered bowel patterns

b. Knowledge Deficit related to disease process and diagnostic procedure

c. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea

d. Anxiety related to unknown outcomes and perceive threat to body integrity


28. Which patient is at greatest risk for pancreatic cancer?

a. An elderly black male with a history of smoking and alcohol use

b. A young, white obese female with no known health issues

c. A young black male with juvenile onset diabetes

d. An elderly white female with a history of pancreatitis


29. The disease progress of cancers, such as cervical or Hodgkin’s, can be classified according to a clinical staging system. Place the description of stages 0-IV in the correct order.

a. Metastasis

b. Limited local spread

c. Cancer in situ

d. Tumor limited to tissue of origin

e. Extensive local and regional spread

_____, _____, _____, _____, _____


30. In assigning patients with alterations related to gastrointestinal (GI) cancer, which would be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of the team leader RN?

a. A patient with severe anemia secondary to GI bleeding

b. A patient who needs enemas and antibiotics to control GI bacteria

c. A patient who needs pre-op teaching for bowel resection surgery

d. A patient who needs central line insertion for chemotherapy


31. A community health center is preparing a presentation on the prevention and detection of cancer. Which health care professional (RN, LPN/LVN, nurse practitioner, nutritionist) should be assigned to address the following topics?

a. Explain screening exams and diagnostic testing for common cancers ____________________________

b. How to plan a balanced diet and reduce fats and preservatives _______________________

c. Prepare a poster on the seven warning signs of cancer ____________________________

d. How to practice breast or testicular self-examination _______________________

e. Strategies for reducing risk factors such as smoking and obesity ___________________________


32. The physician tells the patient that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. You can help the patient by reinforcing that the primary goal for this type of treatment is:

a. Cure

b. Control

c. Palliation

d. Permanent remission


33. For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the nursing assistant?

a. Assist the patient to identify patterns of fatigue.

b. Recommend participation in a walking program.

c. Report the amount and type of food consumed from the tray.

d. Check the skin for redness and irritation after the treatment.


34. For a patient on the chemotherapeutic drug vincristine (Oncovin), which of the following side effects should be reported to the physician?

a. Fatigue

b. Nausea and vomiting

c. Paresthesia

d. Anorexia


35. For a patient who is receiving chemotherapy, which laboratory result is of particular importance?

a. WBC

b. PT and PTT

c. Electrolytes

d. BUN


36. For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?

a. Assist the patient to brush and floss.

b. Explain when brushing and flossing are contraindicated.

c. Give antacids and sucralfate suspension as ordered.

d. Recommend saliva substitutes.


37. When assigning staff to patients who are receiving chemotherapy, what is the major consideration about chemotherapeutic drugs?

a. During preparation, drugs may be absorbed through the skin or inhaled.

b. Many chemotherapeutics are vesicants.

c. Chemotherapeutics are frequently given through central nervous access devices.

d. Oral and venous routes are the most common.


38. You have just received the morning report from the night shift nurses. List the order of priority for assessing and caring for these patients.

a. A patient who developed tumor lysis syndrome around 5:00 AM

b. A patient with frequent reports of break-through pain over the past 24 hours

c. A patient scheduled for exploratory laparotomy this morning

d. A patient with anticipatory nausea and vomiting for the past 24 hours

_____, _____, _____, _____


39. In monitoring patients who are at risk for spinal cord compression related to tumor growth, what is the most likely early manifestation?

a. Sudden-onset back pain

b. Motor loss

c. Constipation

d. Urinary hesitancy


40. Chemotherapeutic treatment of acute leukemia is done in four phases. Place these phases in the correct order.

a. Maintenance

b. Induction

c. Intensification

d. Consolidation

_____, _____, _____, _____


41. Which set of classification values indicates the most extensive and progressed cancer?

a. T1 N0 M0

b. Tis N0 M0

c. T1 N1 M0

d. T4 N3 M1


42. For a patient with osteogenic sarcoma, you would be particularly vigilant for elevations in which laboratory value?

a. Sodium

b. Calcium

c. Potassium

d. Hematocrit


43. Which of the following cancer patients could potentially be placed together as roommates?

a. A patient with a neutrophil count of 1000/mm3

b. A patient who underwent debulking of a tumor to relieve pressure

c. A patient receiving high-dose chemotherapy after a bone marrow harvest

d. A patient who is post-op laminectomy for spinal cord compression


44. What do you tell patients is the most important risk factor for lung cancer when you are teaching about lung cancer prevention?

a. Cigarette smoking

b. Exposure to environmental/occupational carcinogens

c. Exposure to environmental tobacco smoke (ETS)

d. Pipe or cigar smoking


45. Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory value requires particular attention?

a. Platelet count

b. Electrolytes

c. Hemoglobin

d. Hematocrit


46. Persons at risk are the greater target population for cancer screening programs. Which asymptomatic patient(s) needs extra encouragement to participate in cancer screening? (Choose all that apply).

a. A 19-year-old white-American female who is sexually inactive for a Pap smear

b. A 35-year-old white-American female for an annual mammogram

c. A 45-year-old African-American male for an annual prostate-specific antigen

d. A 49year-old African-American male for an annual fecal occult blood test


47. A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the physician, you would anticipate which initial order for the treatment of this patient?

a. A fluid bolus as ordered

b. Fluid restrictions as ordered

c. Urinalysis as ordered

d. Sodium-restricted diet as ordered


48. In caring for a patient with neutropenia, what tasks can be delegated to the nursing assistant? (Choose all that apply).

a. Take vital signs every 4 hours

b. Report temperature elevation >100.4o F

c. Assess for sore throat, cough, or burning with urination.

d. Gather the supplies to prepare the room for protective isolation.

e. Report superinfections, such as candidiasis

f. Practice good handwashing technique.


49. A primary nursing responsibility is the prevention of lung cancer by assisting patients in smoking/tobacco cessation. Which tasks would be appropriate to delegate to the LPN/LVN?

a. Develop a “quit plan”

b. Explain the application of a nicotine patch

c. Discuss strategies to avoid relapse

d. Suggest ways to deal with urges for a tobacco


FLUID, ELECTROLYTE, AND ACID-BASE PROBLEMS

50. A client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to the fluid management should be delegated to a nursing assistant?

a. Administer IV fluids as prescribed by the physician.

b. Provide straws and offer fluids between meals.

c. Develop plan for added fluid intake over 24 hours

d. Teach family members to assist client with fluid intake


51. The client also has the nursing diagnosis Decreased Cardiac Output related to decrease plasma volume.

Which finding on assessment supports this nursing diagnosis?

a. Flattened neck veins when client is in supine position

b. Full and bounding pedal and post-tibial pulses

c. Pitting edema located in feet, ankles, and calves

d. Shallow respirations with crackles on auscultation


52. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for the LPN/LVN being supervised by the nurse? (Choose all that apply.)

a. Remind client to avoid commercial mouthwashes.

b. Encourage mouth rinsing with warm saline.

c. Assess lips, tongue, and mucous membranes

d. Provide mouth care every 2 hours while client is awake

e. Seek dietary consult to increase fluids on meal trays.


53. The physician has written the following orders for the client with Excess Fluid volume. The client’s morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?

a. Weight client every morning.

b. Maintain accurate intake and output.

c. Restrict fluid to 1500 mL per day

d. Administer furosemide (Lasix) 40 mg IV push


54. You have been pulled to the telemetry unit for the day. The monitor informs you that the client has developed prominent U waves. Which laboratory value should you check immediately?

a. Sodium

b. Potassium

c. Magnesium

d. Calcium


55. The client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision?

a. Administer Kayexalate 15 g orally

b. Administer spironolactone 25 mg orally

c. Assess WCG strip for tall T waves

d. Administer potassium 10 mEq orally


56. A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abn0ormality will you be sure to monitor?

a. Hypokalemia

b. Hyperkalemia

c. Hyponatremia

d. Hypernatremia


57. The charge nurse assigned in the care for a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant?

a. Provide oral care every 3-4 hours

b. Monitor for indications of dehydration

c. Administer 0.45% saline by IV line

d. Assess daily weights for trends


58. The experienced LPN/LVN reports that a client’s blood pressure and heart rate have decreased and that when the face is assessed, one side twitches. What action should you take at this time?

a. Reassess the client’s blood pressure and heart rate

b. Review the client’s morning calcium level

c. Request a neurologic consult today

d. Check the client’s papillary reaction to light


59. You are preparing to discharge a client whose calcium level was low but is now just slightly within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for additional teaching?

a. “I will call my doctor if I experience muscle twitching or seizures.”

b. “I will make sure to take my vitamin D with my calcium each day.”

c. “I will take my calcium pill every morning before breakfast.”

d. “I will avoid dairy products, broccoli, and spinach when I eat.”


60. A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?

a. “The client’s low phosphorus is probably due to malnutrition.”

b. “The client is just worn out form not getting enough rest.”

c. “The client’s skeletal muscles are weak because of the low phosphorus.”

d. “The client will do more for herself when her phosphorus is normal”


61. You are reviewing a client’s morning laboratory results. Which of these results is of most concern?

a. Serum potassium 5.2 mEq/L

b. Serum sodium 134 mEq/L

c. Serum calcium 10.6 mg/dL

d. Serum magnesium 0.8 mEq/L


62. You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day?

a. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis

b. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent

c. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on a n insulin drip

d. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis


63. A client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating respiratory acidosis. Which action should you expect to correct this problem?

a. Increase the ventilator rate from 6 to 10 per minute

b. Decrease the ventilator rate from 10 to 6 per minute

c. Increase the oxygen concentration fro 30% to 40%

d. Decrease the oxygen concentration fro 40% to 30%


64. Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.)

a. Check fingerstick glucose every hour.

b. Record intake and output every hour.

c. Check vital signs every 15 minutes.

d. Assess for indicators of fluid imbalance.


65. You are admitting an elderly client to the medical unit. Which factor indicates that this client has a risk for acid-base imbalances?

a. Myocardial infarction 1 year ago

b. Occasional use of antacids

c. Shortness of breath with extreme exertion

d. Chronic renal insufficiency


66. A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately?

a. Respiratory rate of 8 to 10 per minute

b. Pain level decreased from 6/10 to 2/10

c. Client requests room door be closed.

d. Heart rate 90-100 per minute


67. The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect?

a. Respiratory acidosis

b. Respiratory alkalosis

c. Metabolic acidosis

d. Metabolic alkalosis


68. A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report?

a. Repeated episodes of nausea and vomiting

b. Complaints of pain associated with exertion

c. Failure to eat all food on breakfast tray

d. Client hair loss during morning bath


69. A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client’s respiratory rate has increased. What your best response?

a. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate to breathing.”

b. “The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism.”

c. “Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate helps correct the problem.”

d. “The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis.”


ANSWERS AND RATIONALES

1. ANSWER D– As charge nurse, you must assess for the performance and attitude of the staff in relation to this client. After gathering data from the nurses, additional information from the records and the client can be obtained as necessary. The educator may be of assistance if knowledge deficit or need for performance improvement is the problem.

2. ANSWER C – The family is part of the sociocultural dimension of pain. They are influencing the client should be included in the teaching sessions about the appropriate use of narcotics and about the adverse effects of pain on the healing process. The other dimensions should be included to help the client/family understand overall treatment plan and pain mechanism

3. ANSWER A – Antidepressants such as amitriptyline can be given for diabetic neuropathy. Corticosteroids are for pain associated with inflammation. Methylphenidate is given to counteract sedation if the client is on opioids. Lorazepam is an anxiolytic.

4. ANSWER C – Cancer pain generally worsens with disease progression and the use of opioids is more generous. Fibromyalgia is more likely to be treated with non-opiod and adjuvant medicatios. Trigeminal neuralgia is treated with anti-seizure medications such as carbamezapine (Tegretol). Phantom limb pain usually subsides after ambulation begins.

5. ANSWER D - In supervising the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making an ote and watching do not help the nurse to correct the immediate problem. In-service might be considered if the problem persists.

6. ANSWER C – The Faces pain rating scale (depicting smiling, neutral, frowning, crying, etc.) is appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other tools require abstract reasoning abilities to make analogies and use of advanced vocabulary.

7. ANSWER C – The client must be believed and his or her experience of pain must be acknowledged as valid. The data gathered via client reports can then be applied to other options in developing the treatment plan.

8. ANSWER C – the IV route is preferred as the fastest and most amenable to titration. A PCA bolus can be delivered; however, the pump will limit the dosage that can be delivered unless the parameters are changed. Intraspinal administration requires special catheter placement and there are more potential complications with this route. Sublingual is reasonably fast, but not a good route for titration, medication variety in this form is limited.

9. ANSWER A – the goal is to control pain while minimizing side effects. For severe pain, the medication can be titrated upward until pain is controlled. Downward titration occurs when the pain begins to subside. Adequate dosing is important; however, the concept of controlled dosing applies more to potent vasoactive drugs.

10. ANSWER B – Use of heat and cold applications is a standard therapy with guidelines for safe use and predictable outcomes, and an LPN/LVN will be implementing this therapy in the hospital, under the supervision of an RN. Therapeutic touch requires additional training and practice. Meditation is not acceptable to all clients and an assessment of spiritual beliefs should be conducted. Transcutaneous electrical stimulation is usually applied by a physical therapist.

11. ANSWER B, C, A – Step 1 includes non-opioids and adjuvant drugs. Step 2 includes opioids for mild pain plus Step 1 drugs and adjuvant drugs as needed. Step 3 includes opioids for severe pain (replacing Step 2 opioids) and continuing Step 1 drugs and adjuvant drugs as needed.

12. ANSWER D – at greatest risk are elderly clients, opiate naïve clients, and those with underlying pulmonary disease. The child has two of the three risk factors.

13. ANSWER A – This client has strong beliefs and emotions related to the issue of sibling addiction. First, encourage expression. This indicated to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, bearing in mind that their beliefs about drug addiction may be similar to those of the client.

14. ANSWER C – Diaphoresis is one of the early signs that occur between 6 and 12 hours. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours.

15. ANSWER A – The nursing assistant is able to assist the client with hygiene issues and knows the principles of safety and comfort for this procedure. Monitoring the client, teaching techniques, and evaluating outcomes are nursing responsibilities.

16. ANSWER D – the charge nurse is a resource person who can help locate and review the policy. If the physician is insistent, he or she could give the placebo personally, but delaying the administration does not endanger the health or safety of the client. While following one’s own ethical code is correct, you must ensure that the client is not abandoned and that care continues.

17. ANSWER B – Complete information from the family should be obtained during the initial comprehensive history and assessment. If this information is not obtained, the nursing staff will have to rely on observation of nonverbal behavior and careful documentation to determine pain and relief patterns.

18. ANSWER C – If the gastrointestinal system is function, the oral route is preferred for routine analgesics because of lower cost and ease of administration. Oral route is also less painful and less invasive than the IV, IM, subcutaneous, or PCA routes. Transdermal route is slower and medication availability is limited compared to oral forms.

19. ANSWER D – Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps.

20. ANSWER C – The side-lying, knee-chest position opens retroperitoneal space and provides relief. The pillow provides a splinting action. Diversional therapy is not the best choice for acute pain, especially if the activity requires concentration. TENS is more appropriate for chronic muscular pain. The additional stimulation of massage may be distressing to the client.

21. ANSWER D – IF the pain is constant, the best schedule is around-the-clock, to provide steady analgesia and pain control. The other options may actually require higher doses to achieve control

22. ANSWER B, C – The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for pre-operative teaching, and the terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.

23. ANSWER C – When a client takes aspirin, monitor for increases in PT (normal range 11.0-12.5 seconds in 85%-100%). Also monitor for possible decreases in potassium (normal range 3.5-5.0 mEq/L). If bleeding signs are noted, hematocrit should be monitored (normal range male 42%-52%, female 37%-47%). An elevated BUN could be seen if the client is having chronic gastrointestinal bleeding (normal range 10-20 mg/dL).

24. ANSWER B – A second day post-operative client who needs medication prior to dressing changes has predictable and routine care that a new nurse can manage. Although chronic pain clients can be relatively stable, the interaction with this client will be time consuming and may cause the new nurse to fall behind. The HIV client has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions.

25. ANSWER C – directly ask the client about the pain and do a complete pain assessment. This information will determine which action to take next.

CHAPTER 2

CANCER

26. ANSWER A – Oral hygiene is within the scope of responsibilities of the nursing assistant. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The nursing assistant can be directed to weigh the patient, but should not be expected to know when to initiate that measurement.

27. ANSWER D – The patient’s physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic for interventions may be delayed or ignored.

28. ANSWER A – Pancreatic cancer is more common in blacks, males, and smokers. Other links include alcohol, diabetes, obesity, history of pancreatitis, organic chemicals, a high-fat diet, and previous abdominal radiation.

29. ANSWER C, D, B, E, A – This classification system is based on the extent of the disease rather than the histological changes, Stage 0: cancer in situ, stage I: tumor limited to tissue of origin, stage II: limited local spread, stage III: extensive local and regional spread, stage IV: metastasis.

30. ANSWER B – Administering enemas and antibiotics is within the scope of practice for LPN/LVNs. Although some states may allow the LPN/LVN to administer blood, in general, blood administration, pre-operative teaching, and assisting with central line insertion are the responsibilities of the RN>

31. ANSWER A. Nurse Practitioner, B. Nutritionist, C. LPN/LVN, D. Nurse Practitioner, E. RN – The nurse practitioner is often the provider who performs the physical examinations and recommends diagnostic testing. The nutritionist can give information about diet. The LPN/LVN will know the standard seven warning signs and can educate through standard teaching programs in some states. However, the RN has primary responsibility for educating people about risk factors.

32. ANSWER B – The physician has described a treatment for controlling cancer that is not curable. When the goal is cure, the patient will be deemed free of disease after treatments. In palliation, the treatment is given primarily for pain relief. Permanent remission is another term to describe cure.

33. ANSWER C – The nursing assistant can observe the amount that patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue or skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the physician.

34. ANSWER C – Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine (Oncovin). The physician can modify the dose or discontinue the drug. Fatigue, nausea, vomiting, and anorexia are common side effects for many chemotherapy medications. The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and encouraging small meals with high-protein and high-calorie foods.

35. ANSWER A – WBC count is especially important because chemotherapy can cause decreases in WBCs, particularly neutrophils, which leaves the patient vulnerable to infection. The other tests are important in the total management, but less directly specific to chemotherapy.

36. ANSWER C – Giving medications is within the scope of practice for the LPN/LVN. Assisting the patient to brush and floss should be delegated to the nursing assistant. Explaining contraindications is the responsibility of the RN. Recommendations for saliva substitutes should come from the physician or pharmacist.

37. ANSWER A – Ideally, chemotherapy drugs should be given by nurses who have received additional training in how to safely prepare and deliver the drugs and protect themselves from exposure. The other options are a concern but the general principles of drug administration apply.

38. ANSWER A, C, B, D – Tumor lysis syndrome is an emergency of electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment and the physician may need to be contacted for a change of dose or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and antiemetics.

39. ANSWER A – Back pain is an early sign occurring in 95% of patients. The other symptoms are later signs.

40. ANSWER B, C, D, A – Induction is the initial aggressive treatment to destroy leukemia cells. Intensification starts immediately after induction, lasting for several months and targeting persistent, undetected leukemia cells. Consolidation occurs after remission to eliminate any remaining leukemia cells. Maintenance involves lower doses to keep the body free of leukemia cells.

41. ANSWER D – T (tumor) 0-4 signifies tumors increasing size. N (regional lymph nodes) 0-3 signifies increasing involvement of lymph nodes. M (metastasis) 0 signifies no metastasis and 1 signifies distal metastasis.

42. ANSWER B – Potentially life-threatening hypercalcemia can occur in cancers with destruction of bone. Other laboratory values are pertinent for overall patient management but are less specific to bone cancers.

43. ANSWER B, D – Debulking of tumor and laminectomy are palliative procedures. These patients can be placed in the same room. The patient with low neutrophil count and the patient who has had a bone marrow harvest need protective isolation.

44. ANSWER A – Cigarette smoking is associated with 80-90% of lung cancers. Occupational exposure coupled with cigarette smoking increases risks. ETS increases risk by 35%. Cigar smoking provides higher risk than pipe smoking, but both are lower risks than cigarette smoking.

45. ANSWER B – Tumor lysis syndrome can result in severe electrolyte imbalances and potential renal failure. The other laboratory values are important to monitor for general chemotherapy side effects, but are less pertinent to tumor lysis syndrome.

46. ANSWER A, C – After age 18, females should annual Pap smears, regardless of sexual activity. African-American males should begin prostate-specific antigen testing at age 45. Annual mammograms are recommended for women over the age of 40. Annual fecal occult blood testing is recommended starting at age 50.

47. ANSWER B – Hyponatremia is a concern; therefore, fluid restrictions would be ordered. Urinalysis is less pertinent; however, the nurse should monitor for increased urine specific gravity. The diet may need to include sodium supplements. Fluid bolus is unlikely to be ordered for SIADH.

48. ANSWER A, B, D,F – Vital signs and reporting on specific parameters, good hand washing, and gathering equipment are within the scope of duties for an nursing assistant. Assessing for symptoms of infection/superinfections is the responsibility of the RN.

49. ANSWER B – The LPN/LVN is versed in medication administration and able to teach patients standardized information. The other options require more in-depth assessment, planning, and teaching, which should be performed by the RN.

CHAPTER 3

FLUID, ELECTROLYTE, AND ACID-BASE PROBLEMS

50. ANSWER B – The nursing assistant can reinforce additional fluild intake once it is part of the care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice for the RN.

51. ANSWER A – Normally, neck veins are distended when the client is in the supine position. The veins flatten as the client moves to a sitting position. The other three responses are characteristic of Excess Fluid Volume.

52. ANSWER A, B, C, D - The LPN/LVN’s scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPN/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes that contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.

53. ANSWER D – Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but not urgent.

54. ANSWER B – Suspect hypokalemia and check the client’s potassium level. Common ECG changes with hypokalemia include ST depression, inverted T waves, and prominent U waves. Client with hypokalemia may also develop heart block.

55. ANSWER A – The client’s potassium level is high (normal range 3.5-5.0). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the RN.

56. ANSWER C - SIADH causes a relative sodium deficit due to excessive retention of water.

57. ANSWER A – Providing oral care is within the scope of practice for the nursing assistant. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skill of the RN.

58. ANSWER B – A positive Chvostek’s sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The LPN/LVN is experienced and possesses the skills to take accurate vital signs.

59. ANSWER D – Clients with low calcium levels should be encouraged to consume dairy products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium.

60. ANSWER C – A musculoskeletal manifestation of low phosphorous is generalized muscle weakness that may lead to acute muscle breakdown (rhabdomyolysis). Even though the other statements are true, they do not answer the nursing assistant’s question.

61. ANSWER D – While all of these laboratory values are outside of the normal range, the magnesium is most outside of normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

62. ANSWER B – The client with COPD, although ventilator dependent, is the most stable of this group. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy to correct their disorders. In addition, the client with DKA is a new admission and will require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.

63. ANSWER A – the blood gas component responsible for respiratory acidosis is CO2 (Carbon dioxide). Increasing the ventilator rate will blow off more CO2 and decrease the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

64. ANSWER B, C – The nursing assistant’s training and education include how to take vital signs and record intake and output. The need to take vital signs this frequently indicates that the client maybe unstable. The nurse should give the nursing assistant reporting parameters when delegating this action, should also check the vital signs for indications in instability. Performing fingerstick glucose checks and assessing clients require additional education and skill that are appropriate to licensed nurses. Some facilities may train experienced nursing assistants to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this is beyond the normal scope of practice for a nursing assistant.

65. ANSWER D – Risk factors for acid-base imbalances in the older adult include chronic renal disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis.

66. ANSWER A – A decreased respiratory rate indicates respiratory depression which also puts the client at risk for respiratory acidosis, All of the other findings are important and should be reported to the RN, but the respiratory rate is urgent.

67. ANSWER B – The client is most likely hyperventilating and blowing off CO­2. This decrease in CO2 will lead to an increase in pH, causing respiratory alkalosis. Respiratory acidosis results from respiratory depression and retained CO2. Metabolic acidosis and alkalosis result from problems related to renal acid-base control.

68. ANSWER A – Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.

69. ANSWER B – Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client’s increase in rate and depth of ventilation is an attempt to compensate by blowing off CO2. the first response maybe true but does not address all the components of the question. The third and fourth answers are inaccurate.

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