Monday, February 23, 2009

NCLEX PRACTICE Q & A 002 WITH RATIONALE

1. The physician ordered digoxin (Lanoxin) 0.125 mg p.o.
every day. The nurse has digoxin 0.25 mg scored tablets.
How many tablet(s) should the nurse administer?
a. 1⁄2 tablet
b. 1 tablet
c. 11⁄2 tablet
d. 2 tablets

Rationale
Correct answer: a.
Answer (a) is correct: 0.125 mg/x tablet _ 0.25 mg/1
tablet
0.25x _ 0.125
x _ 1⁄2 tablet

2. Which of the following classes of drugs would most
likely predispose a client to digitalis toxicity?
a. Salicylate analgesics
b. Tetracycline antibiotics
c. Diuretics
d. Barbiturates

Rationale
Correct answer: c.
Answer (c) is correct because many diuretics increase the
excretion of potassium from the body and a decreased
level of potassium increases the risk of digoxin toxicity.
Answers (a),(b), and (d) do not predispose a client to
digoxin toxicity.

3. The nurse is providing care for a client who is receiving
digoxin (Lanoxin). Which of the following symptoms
should the nurse recognize as digoxin (Lanoxin)
toxicity?
a. Hyperkalemia
b. Increased hunger
c. Constipation
d. Visual disturbances

Rationale
Correct answer: d.
Answer (d) is correct because it is a common symptom of
digoxin toxicity. Other symptoms include fatigue,
anorexia, blurred or double vision, nausea, confusion,
and bradycardia. Answers (a), (b), and (c) are not symptoms
of digoxin toxicity.
4. A client comes to the clinic complaining of unexplained
black and blues and bloody appearing urine.
Which type of medication is it most important to find
out if the client is taking?
a. Antibiotic
b. Antipruritic
c. Antianemic
d. Anticoagulant

Rationale
Correct answer: d.
Answer (d) is correct because a side effect of anticoagulant
therapy is abnormal bleeding, which can manifest in
many ways two of which are as gross blood in the urine
and easy bruising.

5. A client was admitted to the hospital with pneumonia.
The physician ordered “Zinacef, (a second generation
cephalosporin) 2 g IV q 8 hour.” While preparing
to administer the first dose of Zinacef, the nurse
notices that this client has a penicillin allergy. The
best action by the nurse is to:
a. administer the Zinacef as ordered but watch the
client carefully for any signs of an allergic reaction
b. ask the pharmacist if another antibiotic can be
substituted for the Zinacef
c. administer the Zinacef as ordered
d. hold the Zinacef and notify the physician of the
client’s allergy to penicillin

Rationale
Correct answer: d.
Answer (d) is the best answer. Often, a client who has an
allergy to Penicillin will experience an adverse effect to the
cephalosporin class of antibiotics because they are chemically
and pharmacologically similar. Therefore, for the
safety of the client, the nurse should always call the physician.
The answers of (a), (b), and (c) are not appropriate
actions for the nurse to take with this client situation.

6. The physician prescribes an antihypertensive medication
for your client. As a nurse, you would instruct
the client to..
a. limit fluid intake to 1200 ml daily.
b. increase activities, but limit foods high in magnesium.
c. take a laxative along with the antihypertensive
mediation.
d. change positions slowly, and sit up for a few minutes
before rising from a lying position.

Rationale
Correct answer: d.
Answer (d) is correct. Many of the antihypertensive medications
cause orthostatic hypotension. Therefore, the
nurse should instruct the client regarding sudden movements
and about rising slowing to prevent a decrease in
BP and prevent client injury. Answers (a), (b), and (c) are
not appropriate instructions in regards to medications
for hypertension.

7. A client, who is 6-months pregnant, comes to the
physician asking for a prescription for a tetracycline
type medication to treat her acne. Your response
should be
a. “Tetracycline, if taken during pregnancy, may be
deposited in the bones and teeth of the fetus.”
b. “The effect of tetracycline is decreased during
pregnancy.”
c. “Tetracycline may cause renal failure if taken during
pregnancy.”
d. “Taking tetracycline during pregnancy may cause
your teeth to discolor.”

Rationale
Correct answer: a.
Answer (a) is correct because the tetracycline medications
are contraindicated during pregnancy because the
drugs may interfere with normal calcification of temporary
and permanent teeth and discolor developing teeth
of the fetus. The drug may also interfere with bone
growth of the fetus. Answers (b) and (c) are incorrect.
Answer (d) is incorrect because the medication affects
the developing teeth of the fetus and children younger
than 8 years of age, not the adult.

8. You have just finished instructing your client on
measures to help the body fight infections. Which of
the following statements by your client would lead
you to believe he needs additional instruction regarding
the antibiotics?
a. “I will make sure I get adequate rest.”
b. “I know I must continue to eat a balanced diet and
drink lots of fluids.”
c. “I will take my medicine until I no longer have a
fever.”
d. “I will wash my hands often.”

Rationale
Correct answer: c.
Answer (c) is correct. The question is asking how the
nurse would know the client needs additional instruction
or that the client does not understand. If the client
thinks he should stop taking his antibiotics when he no
longer has a fever, then he needs additional education.
Answers (a), (b), and (d) are all good measures to help
fight or prevent infection, therefore, these do not indicate
he needs more instruction.

9. The nurse should provide client education as an integral
component of client care. Clients taking captopril
(Capoten) should be informed that they may experience
a common adverse effect of the angiotension-converting
enzyme inhibitors (ACE inhibitors) such as
a. Persistent cough
b. Increased appetite
c. Hypertension
d. Sedation

Rationale
Correct answer: a.
Answer (a) is correct. A persistent cough is a common
adverse effect of ACE Inhibitors. Answers (b), (c), and
(d) are not common adverse effects of ACE Inhibitors.

10. A client was prescribed both heparin (Calcilean) and
warfarin (Coumadin) by the physician. When preparing
to administer both of these anticoagulants, what
rationale would the nurse consider appropriate?
a. It takes 12–24 hours before the action of oral anticoagulants
is evident.
b. Heparin (Calcilean) is more effective when used
with warfarin sodium (Coumadin).
c. By administering an oral anticoagulant with
heparin (Calcilean), the client needs less frequent
administration of heparin.
d. The client is less likely to experience adverse effects

Rationale
Correct answer: a.
Answer (a) is correct. In many situations the client is
receiving heparin intravenously and the physician prescribes
the addition of Coumadin for several days prior
to discontinuing the heparin. For oral anticoagulants,
their effect is usually not evident for 12–24 hours after
therapy has begun. Therefore, the client is receiving the
heparin while the effects of the Coumadin are beginning
to become evident. After the laboratory work shows evidence
that the oral anticoagulants are effective, then the
physician will discontinue the heparin therapy. Answers
(b),(c), and (d) are not correct.

11. The nurse needs to administer two types of insulin to the
client. Which of the following is the correct procedure
for mixing two types of insulin in the same syringe?
a. Withdraw the regular insulin prior to any other
type of insulin.
b. Withdraw the regular insulin after other types of
insulin.
c. Draw each of the insulin medications in a separate
syringe then combine the two.
d. Withdraw one half dose of the regular insulin
prior to the other insulin, and then withdraw the
remaining dose of the regular insulin.

Rationale
Correct answer: a.
Answer (a) is correct. The nurse withdraws the regular
(clear) insulin first so as to not contaminate the regular
insulin vial with the other types of insulin. Answers (b)
and (d) risk the chance to contaminate the regular
insulin vial. Answer (c) indicates that the nurse is wasting
time and supplies, as well as the insulin syringes do
not have a detachable needle, thus, the nurse can not
add solution from one syringe to another syringe.


12. Which statement made by a client following teaching
about the importance of using only unsaturated fats
when cooking indicates that information about
which fats are unsaturated was understood?
a. “I will use butter when cooking.”
b. “I will use olive oil when cooking.”
c. “I will use lard when cooking.”
d. “I will use palm oil when cooking.”

Rationale
Correct answer: b.
Olive oil is an unsaturated fat.
Butter, lard, and palm oil are all saturated fats.

13. When caring for a client taking phenytoin (Dilantin),
the nurse assesses the client’s mouth for which side
effect of the drug?
a. Gum hyperplasia
b. Thrush
c. Dental caries
d. Glossitis

Rationale
Correct answer: a.
Gingival hyperplasia is a common side effect of the drug
Dilantin.

14. When administering mouth care to an unconscious
client, the nurse would place the client into which
position?
a. Dorsal recumbent
b. High-Fowler’s
c. Supine
d. Side-lying
Rationale

Correct answer: d.
Placing the client in the side-lying position greatly
decreases the risk of aspiration when performing oral
hygiene on a comatose client.

15. Which data should the nurse review to most accurately
assess a client’s protein stores?
a. Urinary protein
b. Triceps skinfold measurement
c. Plasma albumin
d. Height and weight

Rationale
Correct answer: c.
Albumin is manufactured by the liver from dietary proteins.
In the absence of other diseases, clients with adequate protein
intake should have normal serum albumin levels.

16. Which nursing order related to nutrition should be
included in the plan of care for a client with limited
vision?
a. Assess for presence of the gag reflex
b. Orient to type and location of foods and utensils
c. Feed in the client’s preferred order of eating
d. Cut foods, then remove knife from tray
Rationale
Correct answer: b.
Orienting the client to the food placement on the tray
encourages independence in feeding and increases selfesteem
in the client with limited vision.

17. By which route does the nurse administer parenteral
nutrition?
a. Intravenous
b. Nasogastric
c. Intra-arterial
d. Nasoenteric

Rationale
Correct answer: a.
Parenteral nutrition is the nutrition administered directly
into a vein.

18. The nurse performs range of motion exercises on an
immobile client to avoid which complication associated
with immobility?
a. Urinary stasis
b. Constipation
c. Dependent edema
d. Contractures
Rationale
Correct answer: d.
During periods of immobility, the muscle fibers shorten
and atrophy, pulling the extremity into a position of flexion
and fixation. Exercising the extremity can prevent this
from occurring.

19. Which nursing intervention should receive priority
when caring for an immobile client?
a Repositioning every 2 hours
b. Assessing for dependent edema each shift
c. Auscultating for bowel sounds daily
d. Administering a calcium supplement twice a day

Rationale
Correct answer: a.
Immobile clients are at a high risk for pressure ulcer
development. Should this occur, the client is at an
increased risk for infection and septicemia. Prevention of
impaired skin integrity is a high priority.

20. Which nursing intervention would best promote a
client’s psychospiritual comfort?
a. Offering a back rub
b. Maintaining a clean environment
c. Encouraging expression of feeling
d. Providing mouth and hair care
Rationale
Correct answer: c.
Encouraging clients to identify and verbalize their feelings
is therapeutic.

21. Use of a nasoenteric tube is the method of choice for
the administration of enteral feedings when the client
is at risk for which problem?
a. Diarrhea
b. Infection
c. Aspiration
d. Hyperkalemia

Rationale
Correct answer: c.
Nasoenteric tubes deliver nutrients directly into the intestines,
and therefore greatly reduce the risk for aspiration.

5 comments:

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  2. wow! i am impressed with the rationales given here. I'm glad I found this site. To those who recently pass the NCLEX please share the latest questions to us. I know in return, someone up there will reward your kindness in helping others- Grace

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