NCLEX-PN Practice Exam 5
The physician has ordered a low-potassium diet for a child with acute glomerulonephritis. Which snack is suitable for the child with potassium restrictions?
Apricots are low in potassium; therefore, it is a suitable snack of the client on a potassium-restricted diet. Raisins, oranges, and bananas are all good sources of potassium; therefore, answers A, B, and C are incorrect.
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
No special preparation is needed for the blood test for H. pylori. Answer A is incorrect because the client is not NPO before the test. Answer C is incorrect because it refers to preparation for the breath test. Answer D is incorrect because glucose is not administered before the test.
The nurse is preparing to give an oral potassium supplement. The nurse should:
Oral potassium supplements should be given in at least 4oz. of juice or other liquid, to prevent gastric upset and to disguise the unpleasant taste. Answers A, C, and D are incorrect because they cause gastric upset.
The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true regarding collection of cultures for cytomegalovirus?
Fresh specimens are essential for accurate diagnosis of CMV. Answer A is incorrect because cultures of urine, sputum, and oral swab are preferred. Answer B is incorrect because pregnant caregivers should not be assigned to care for clients with suspected or known infection with CMV. Answer C is incorrect because a convalescent culture is obtained 2–4 weeks after diagnosis.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
The client should receive pain medication 30 minutes before the application of Sulfamylon. Answer A is incorrect because it refers to silver nitrate. Answer B is incorrect because it refers to Silvadene. Answer C is incorrect because it refers to Betadine.
The physician has ordered Dilantin (phenytoin) for a client with generalized seizures. When planning the client’s care, the nurse should:
Gingival hyperplasia is a side effect of Dilantin; therefore, the nurse should provide oral hygiene and gum care every shift. Answers A, B, and C do not apply to the medication; therefore, they are incorrect.
A client receiving chemotherapy for breast cancer has an order for Zofran (ondansetron) 8mg PO to be given 30 minutes before induction of the chemotherapy. The purpose of the medication is to:
Zofran is given before chemotherapy to prevent nausea. Answers A, B, and D are not associated with the medication; therefore, they are incorrect.
The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
When administering ear drops to a child under 3 years of age, the nurse should pull the ear down and back to straighten the ear canal. Answers B and D are incorrect positions for administering ear drops. Answer C is used for administering ear drops to an adult client.
A client with schizophrenia has been taking Thorazine (chlorpromazine) 200 mg four times a day. Which finding should be reported to the doctor immediately?
The nurse should carefully monitor the client taking Thorazine for signs of infection that can quickly become overwhelming. Answers A, B, and C are incorrect because they are expected side effects of the medication.
A client with iron-deficiency anemia is taking an oral iron supplement. The nurse should tell the client to take the medication with:
Iron is better absorbed when taken with ascorbic acid. Orange juice is an excellent source of ascorbic acid. Answer B is incorrect because the medication should be taken with orange juice or tomato juice. Answer C is incorrect because iron should not be taken with milk because it interferes with absorption. Answer D is incorrect because apple juice does not contain high amounts of ascorbic acid.
A client is admitted with burns of the right arm, chest, and head. According to the Rule of Nines, the percent of burn injury is:
Burn injury of the arm (9%), chest (9%), and head (9%) accounts for burns covering 27% of the total body surface area. Answers A, C, and D are incorrect percentages.
A client who was admitted with chest pain and shortness of breath has a standing order for oxygen via mask. Standing orders for oxygen mean that the nurse can apply oxygen at:
With standing orders, the nurse can administer oxygen at 6L per minute via mask. Answer A is incorrect because the amount is too low to help the client with chest pain and shortness of breath. Answers C and D have oxygen levels requiring a doctor’s order.
The nurse is caring for a client with an ileostomy. The nurse should pay careful attention to care around the stoma because:
Stool from the ileostomy contains digestive enzymes that can cause severe skin breakdown. Answer B contains contradictory information; therefore, it is incorrect. Answers C and D contain inaccurate statements; therefore, they are incorrect.
The physician has ordered aspirin therapy for a client with severe rheumatoid arthritis. A sign of acute aspirin toxicity is:
Tinnitus is a sign of aspirin toxicity. Answers A, B, and D are not related to aspirin toxicity; therefore, they are incorrect.
A client is admitted to the emergency room with symptoms of delirium tremens. After admitting the client to a private room, the priority nursing intervention is to:
The client with delirium tremens has an increased risk for seizures; therefore, the nurse should provide seizure precautions. Answer A is not a priority in the client’s care; therefore, it is incorrect. Answer C is incorrect because the client should be kept in a dimly lit, not dark, room. Answer D is incorrect because thiamine and multivitamins are given to prevent Wernicke’s encephalopathy, not delirium tremens.
The nurse is providing dietary teaching for a client with gout. Which dietary selection is suitable for the client with gout?
Steak, baked potato, and tossed salad are lower in purine than the other choices. Liver, crab, and chicken are high in purine; therefore, answers A, B, and C are incorrect.
A newborn has been diagnosed with exstrophy of the bladder. The nurse should position the newborn:
Placing the newborn in a side-lying position helps the urine to drain from the exposed bladder. Answer A is incorrect because it would position the child on the exposed bladder. Answers B and D are incorrect because they would allow the urine to pool.
The mother of a 3-month-old with esophageal reflux asks the nurse what she can do to lessen the baby’s reflux. The nurse should tell the mother to:
Burping the baby frequently throughout the feeding will help prevent gastric distention that contributes to esophageal reflux. Answers A and B are incorrect because they allow air to collect in the baby’s stomach, which contributes to reflux. Answer C is incorrect because the baby should be placed side-lying with the head elevated, to prevent aspiration.
A child is hospitalized with a fractured femur involving the epiphyseal plate. Epiphyseal fractures are serious because:
Growth plates located in the epiphysis can be damaged by epiphyseal fractures. Answers A, B, and C are untrue statements; therefore, they are incorrect.
Before administering a nasogastric feeding to a client hospitalized following a CVA, the nurse aspirates 40 mL of residual. The nurse should:
The nurse should replace the aspirate and administer the feeding because the amount aspirated was less than 50mL. Answers B and C are incorrect because the aspirate should not be discarded. Answer D is incorrect because the feeding should not be withheld.
A client has an order for Dilantin (phenytoin) .2g orally twice a day. The medication is available in 100mg capsules. For the morning medication, the nurse should administer:
The nurse should administer two capsules. Answers A, C, and D contain inaccurate amounts; therefore, they are incorrect.
The LPN is reviewing the lab results of an elderly client when she notes a specific gravity of 1.006. The nurse recognizes that:
The normal specific gravity is 1.005-1.030. Answers A, C, and D are inaccurate statements; therefore, they are incorrect.
A client with pancreatitis has requested pain medication. Which pain medication is indicated for the client with pancreatitis?
To prevent spasms of the sphincter of Oddi, the client with pancreatitis should receive non opiate analgesics for pain. Answer B is incorrect because the client with pancreatitis might be prone to bleed; therefore, Toradol is not a drug of choice for pain control. Morphine and codeine, opiate analgesics, are contraindicated for the client with pancreatitis; therefore, answers C and D are incorrect.
A client with a hiatal hernia has been taking magnesium hydroxide for relief of heartburn. Overuse of magnesium-based antacids can cause the client to have:
Overuse of magnesium-containing antacids results in diarrhea. Antacids containing calcium and aluminum cause constipation; therefore, answer A is incorrect. Answers B and C are not associated with the use of magnesium antacids; therefore, they are incorrect.
When performing a newborn assessment, the nurse measures the circumference of the neonate’s head and chest. Which assessment finding is expected in the normal newborn?
The head circumference of the normal newborn is approximately 33cm, while the chest circumference is 31cm. Answer A is incorrect because the head and chest are not the same circumference. Answer C is incorrect because the head is larger in circumference than the chest. Answer D is incorrect because the difference in head circumference and chest circumference is too great
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