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NCLEX 11-15

Multiple Choice
Identify the choice that best completes the statement or answers the question.
 

 1. 

A client was transferred to the nursing unit from the coronary care unit after experiencing a myocardial infarction (MI). When reviewing the client’s serum creatinine phosphokinase (CPK) levels recorded in the chart, the nurse knows that an elevation of which of the following was due to the MI?
a.
MB
b.
MM
c.
MK
d.
BB
 

 2. 

A client with history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client’s blood level of the medication is within the normal range if the value reported is:
a.
15 mcg/mL
b.
6 mcg/mL
c.
28 mcg/mL
d.
35 mcg/mL
 

 3. 

A long-term-care nurse about to give a daily dose of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which of the following actions first?
a.
Gather data from the client related to signs of toxicity.
b.
Report the finding to the health care provider.
c.
Record the normal value on the intershift report sheet.
d.
Administer the daily dose of the medication.
 

 4. 

A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client’s baseline before the initiation of therapy was 30 seconds. The LPN should take which of the following actions?
a.
Leave the report for the registered nurse (RN) to review later in the day.
b.
Ask the client about worsening pain from the DVT.
c.
Notify the RN about the value immediately.
d.
Check to see if additional heparin is available on the unit.
 

 5. 

A client is receiving oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn prothrombin time (PT) is 28 seconds. The nurse anticipates carrying out an order to:
a.
Hold the next dose of warfarin.
b.
Stop the warfarin and administer heparin.
c.
Administer the next dose of warfarin.
d.
Increase the next dose of warfarin.
 

 6. 

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which of the following results?
a.
Chloride 103 mEq/L
b.
Bicarbonate 24 mEq/L
c.
Sodium 142 mEq/L
d.
Potassium 5.4 mEq/L
 

 7. 

A nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which of the following could cause a false-negative result?
a.
Iodine
b.
Acetylsalicylic acid
c.
Ascorbic acid
d.
Colchicine
 

 8. 

An older client has been treated for dehydration and pneumonia. The nurse evaluates that the client’s dehydration has been successfully treated if the blood urea nitrogen (BUN) level drops to:
a.
19 mg/dL
b.
5 mg/dL
c.
46 mg/dL
d.
32 mg/dL
 

 9. 

A nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which of the following substances in CSF?
a.
Protein
b.
Glucose
c.
White blood cells
d.
Red blood cells
 

 10. 

A nurse has provided dietary instructions to a client with renal calculi who must learn to eat an alkaline-ash diet. The nurse determines that the client has properly understood the information presented if the client chooses which of the following selections from a diet menu?
a.
Chicken, potatoes, and cranberries
b.
Peanut butter sandwich, milk, and prunes
c.
A spinach salad, milk, and a banana
d.
Linguini with shrimp, tossed salad, and a plum
 

 11. 

A client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed would include which of the following in a list provided to the client?
a.
Tomato soup
b.
Summer squash
c.
Instant oatmeal
d.
Boiled shrimp
 

 12. 

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which of the following fruits?
a.
Apples
b.
Pears
c.
Bananas
d.
Cranberries
 

 13. 

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are on which of the following diets?
a.
A high-carbohydrate diet
b.
A low-fat diet
c.
A high-fat diet
d.
A low-fiber diet
 

 14. 

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat which of the following foods that are naturally high in vitamin C to promote wound healing?
a.
Chicken
b.
Bananas
c.
Oranges
d.
Milk
 

 15. 

A client with a brain attack (stroke) is experiencing residual dysphagia. The nurse would remove which of the following food items that arrived on the client’s meal tray from the dietary department?
a.
Mashed potatoes
b.
Peas
c.
Cheese casserole
d.
Scrambled eggs
 

 16. 

A client is resuming a diet after hemigastrectomy. To minimize complications, the nurse would tell the client to avoid doing which of the following?
a.
Eating six small meals per day
b.
Excluding concentrated sweets in the diet
c.
Lying down after eating
d.
Drinking liquids with meals
 

 17. 

A client who has developed atrial fibrillation that is not responding to medication therapy has begun taking warfarin (Coumadin). The nurse is doing discharge dietary teaching with the client. The nurse would plan to teach the client to avoid which of the following foods while taking this medication?
a.
Cherries
b.
Potatoes
c.
Spaghetti
d.
Broccoli
 

 18. 

A nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy?
a.
Calcium intake should be increased for the duration of the pregnancy.
b.
Iron supplements should be taken throughout pregnancy.
c.
The maternal diet significantly influences fetal growth and development.
d.
Pregnancy greatly increases the risk of malnourishment for the mother.
 

 19. 

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that is most likely to have this taste for the client?
a.
Beef
b.
Potatoes
c.
Custard
d.
Cantaloupe
 

 20. 

A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients every:
a.
1 hour
b.
2 hours
c.
3 hours
d.
4 hours
 

 21. 

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer’s at 80 mL/hour to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that the completion time for the bag is:
a.
15:30
b.
17:30
c.
19:30
d.
21:30
 

 22. 

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?
a.
There is less pain and discomfort.
b.
This type of catheter is very reliable.
c.
It is reasonable in cost.
d.
It is specifically designed for short-term use.
 

 23. 

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN would plan to avoid which of the following actions in the care of this client?
a.
Prepare to apply warm moist packs to the site.
b.
Prepare to start a new line in a proximal portion of the same vein.
c.
Prepare to discontinue the IV catheter at that site.
d.
Notify the registered nurse (RN).
 

 24. 

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?
a.
Sit the client up in bed.
b.
Place the client in Trendelenburg’s position.
c.
Shut off the infusion.
d.
Discontinue the angiocatheter and IV.
 

 25. 

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse?
a.
Wipe the tubing port with povidone-iodine.
b.
Scrub the needleless device with an alcohol swab.
c.
Attach a new needleless device.
d.
Change the IV tubing.
 

 26. 

A nurse enters a client’s room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client’s lung sounds and notes the presence of crackles in the lung bases. The client states that she was just going to ring the call bell for the nurse. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy?
a.
Hypovolemic shock
b.
Transfusion reaction
c.
Fluid overload
d.
Bacteremia
 

 27. 

A nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is most important to immediately report which of the following signs if they occur?
a.
Fatigue
b.
Nausea
c.
Headache
d.
Backache
 

 28. 

A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?
a.
Wears gloves, gown, and goggles when changing the client’s colostomy bag
b.
Wears a gown when caring for the client and removes the gown immediately after leaving the client’s room
c.
Places the client in a semiprivate room with another client who has active infection with the same microorganism but who has no other infection
d.
Places the client in a private room
 

 29. 

A nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which of the following nursing actions would be most appropriate in preparing the client for the test?
a.
Ask that the MRI department be called to tell the technician that the test will have to be delayed until the airborne precautions are discontinued.
b.
Plan to have the MRI performed at the bedside.
c.
Ask that the MRI department be called to tell technicians in the department to wear masks.
d.
Place a surgical mask on the client for transport and for contact with other individuals.
 

 30. 

A nurse employed in the ambulatory care department hears a client in the waiting room call out, “Help, fire!” The nurse rushes to the waiting room and finds the wastebasket on fire. The nurse immediately:
a.
Removes the clients from the waiting room
b.
Activates the fire alarm
c.
Confines the fire
d.
Extinguishes the fire
 

 31. 

A nurse is instructing a group of nursing assistants in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the nursing assistant:
a.
Positioning a box that is to be lifted between the knees
b.
Turning the back to change position while moving a client
c.
Helping a client requiring total care into a chair without additional assistance
d.
Leaning forward when turning a client in bed
 

 32. 

A nurse is working in a long-term care facility and is observing a new nursing assistant caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the nursing assistant assessing skin integrity by completely removing the client’s wrist restraints:
a.
Every 2 hours
b.
Every 3 hours
c.
Every 4 hours
d.
Every 6 hours
 

 33. 

A nurse is assisting in developing a plan of care for an older client to prevent a fall. Which of the following actions would be least likely to prevent a fall?
a.
Placing the bed in the lowest position
b.
Placing the call light within the client’s reach
c.
Keeping the bathroom light off at nighttime
d.
Keeping the side rails up while the client is in bed
 

 34. 

A physician writes an order to apply a heating pad to a client’s back. The nurse implements the prescribed order and avoids which of the following?
a.
Setting the heating pad on a low setting
b.
Placing the heating pad under the client
c.
Assessing the heating pad periodically for proper electrical function
d.
Assessing the skin integrity frequently for signs of burns
 

 35. 

A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to:
a.
Keep the ice pack on the eye continuously for 24 hours.
b.
Place the ice pack directly on the eye.
c.
Avoid the use of commercially prepared ice bags.
d.
Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.
 

 36. 

A nurse is preparing to clean up a blood spill on the client’s bedside table. The spill occurred when a blood tube containing the client’s blood specimen broke. The nurse avoids doing which of the following when cleaning up the blood spill?
a.
Wearing gloves for the cleanup procedure
b.
Using tongs to collect any broken glass
c.
Blotting up the spill with a face cloth or cloth towel
d.
Disinfecting the area of the blood spill with a dilute bleach solution
 

 37. 

A physician orders 1000 mL of 0.9% normal saline (NS) to run over 8 hours. The drop (gt) factor is 10 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many gtt per minute?
a.
15 gtt/minute
b.
17 gtt/minute
c.
21 gtt/minute
d.
23 gtt/minute
 

 38. 

A physician prescribes meperidine hydrochloride (Demerol), 40 mg intramuscularly stat, for a postoperative client in pain. The medication label states meperidine hydrochloride, 50 mg/mL. How many mL will the nurse prepare to administer to the client?
a.
0.5 mL
b.
0.6 mL
c.
0.8 mL
d.
1 mL
 

 39. 

A physician prescribes atenolol (Tenormin) 0.05 g by mouth daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablets will the nurse administer to the client?
a.
0.5 tablet
b.
1 tablet
c.
2 tablets
d.
3 tablets
 

 40. 

A client is to receive 1000 mL of 5% dextrose in water (D5W) at a rate of 100 mL/hour. The drop (gt) factor is 10 drops (gtt) per mL. The nurse adjusts the flow rate to deliver how many gtt per minute?
a.
10 gtt
b.
13 gtt
c.
17 gtt
d.
20 gtt
 

 41. 

A physician orders an intramuscular (IM) dose of 250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose?
a.
0.25 mL
b.
0.8 mL
c.
1.5 mL
d.
8 mL
 

 42. 

A physician orders a bolus of 500 mL of 0.9% normal saline (NS) to run over 4 hours. The drop (gt) factor is 10 drops (gtt) per 1 mL. The nurse plans to adjust the flow rate at how many gtt per minute?
a.
15 gtt
b.
17 gtt
c.
19 gtt
d.
21 gtt
 

Completion
Complete each statement.
 

 43. 

A physician prescribes digoxin (Lanoxin), 0.25 mg by mouth (PO) daily, for a client with congestive heart failure. The medication label states 0.125 mg per tablet. How many tablet(s) will the nurse administer to the client?
 

 

 44. 

Ampicillin sodium (Omnipen) 250 mg in 50 mL of normal saline (NS) is being administered over a period of 30 minutes. The drop (gt) factor is 10 drops (gtt) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many gtt per minute? (Round answer to the nearest whole number.)
 

 

 45. 

A physician prescribes 1000 mL of normal saline (NS) to be infused over a period of 10 hours. The drop (gt) factor is 15 drops (gtt) per mL. The nurse adjusts the flow rate at how many gtt per minute?
 

 

 46. 

A physician orders 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop (gt) factor is 15 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many gtt per minute? (Round answer to the nearest whole number.)
 

 



 
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