NCLEX.txt

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NCLEX.txt
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  1. A client has a yeast infection. What category of microorganism is yeast?

    Bacteria
    Fungi
    Parasites
    Viruses
    Fungi

    Rationale: Fungi include yeasts and molds. Bacteria include organisms like staphylococcus and streptococcus. Parasites live on other living organisms and include protozoa, worms, and fleas. Viruses include rhinovirus, hepatitis, herpes and HIV.
  2. What are the major categories of microorganisms that cause infections in humans? (Select all that apply.)

    Bacteria
    Colonization
    Viruses
    Parasites
    • Bacteria
    • Viruses
    • Parasites
  3. What are the most common infecting microorganisms in nosocomial infections? (Select all that apply.)

    Escherichia coli
    Enterococci
    Staphylcoccus aureus
    Serratia
    • Escherichia coli
    • Enterococci
    • Staphylcoccus aureus

    See KOZ 673
  4. The nurse notes hyperemia when evaluating the incision of a client. The nurse knows that this indicates what stage in the inflammatory response?

    Vascular and cellular response
    Exudate production
    Reparative phase
    Margination
    Vascular and cellular response

    Rationale: Hyperemia indicates a marked increase in blood supply, and is the first stage of the inflammatory response. The vascular and cellular response is the first stage. Exudate production is the second stage. Reparative phase is the third stage. Margination is part of the first stage.

    see KOZ 676
  5. What type of immunity is lost when a client develops human immunodeficiency virus (HIV)?

    Active immunity
    Passive immunity
    Humoral immunity
    Cellular immunity
    Cell mediated

    Rationale: Cellular immunity, which occurs through the T-cell system, is lost with HIV. Active immunity occurs in response to an infection or vaccines. Passive immunity occurs through an injection of immune serum, or, for an infant, from breastfeeding. Antibodies produced by B cells mediate humoral immunity.

    see KOZ 677
  6. A hospitalized client is in a private room. When outside the room, the client must wear a surgical mask. What type of isolation precaution is in use?

    Airborne
    Contact
    Droplet
    Standard
    Droplet

    Rationale: Droplet precautions involve use of mask to prevent passing to others. Airborne precautions require an isolation room, and the client is not allowed outside the room. Contact precautions involve gown and glove for direct client contact. This client would not be out of the room. Standard precaution is the global term for all types of precautions.
  7. A home health nurse has just changed a soiled dressing from an infected wound of a client's. After placing the soiled dressing in a paper bag provided by the client, how should the nurse dispose of it?

    Place the paper bag inside a plastic bag for disposal.
    Throw the paper bag into a garbage can.
    Take the bag home and dispose of it.
    Ask the client to dispose of the bag.
    Place the paper bag inside a plastic bag for disposal.
  8. A client with tuberculosis is expecting visitors, and asks if they need to wear masks if they are healthy. What response by the nurse would be most accurate?

    "Only the visitors who will have close contact with you need to wear a mask."
    "Visitors do not need to be concerned. Only the health care workers need a mask."
    "Everyone who enters your room must wear a mask to protect themselves from tuberculosis."
    "Only visitors who might be at risk to get this disease should wear a mask."
    "Everyone who enters your room must wear a mask to protect themselves from tuberculosis."
  9. A client has been diagnosed with a urinary tract infection. What is the most likely cause of this infection?

    Staphylococcus aureus
    Escherichia coli enterococci
    Neisseria gonorrhoeae
    Streptococcus beta-hemolytic A or B
    Escherichia coli enterococci

    Rationale: Escherichia coli enterococci are the most common infectious organism. Staphylococcus is common in the respiratory tract and blood. Neisseria gonorrhoeae is common in the reproductive tract. Streptococcus A or B is common in tissues.
  10. A mother is planning on weaning her 5-month-old infant from breastfeeding. She says that the infant may get my infections, since the baby will not be getting immunity through her breast milk. What response by the nurse would be most appropriate?

    "Infections are a major cause of death in newborns, so you may want to reconsider."
    "You baby will be fine; the natural immunity will continue until the baby produces its own antibodies."
    "Infants begin to make their own immunity between 1 and 3 months of age."
    "Just don't allow your infant to get the DPT until 1 year of age if you stop breastfeeding now."
    "Infants begin to make their own immunity between 1 and 3 months of age."

    Rationale: The newborn does begin to synthesize its own immunoglobulins between 1 and 3 months of age. Infections are a major cause of death in newborns, but that is not the reason to consider continuation of breastfeeding. The other answers are inaccurate and not reassuring.
  11. One of the roles as the nurse when providing client care is to thoroughly assess a client's vital signs.

    Although vital signs can be delegated to the unlicensed assistant, what responsibility lies with the nurse concerning vital signs?
    The nurse retains accountability for assessment, evaluation and use of the vital signs, as well as their documentation.

    (The nurse must be aware of the vital signs and take action when the vital signs are abnormal.)
  12. An adult's vital signs in relation to a 10-year-old's will be higher in what areas?
    Blood Pressure is the only vital that will normally be higher in adults. 10 year old Children will have higher pulses and respirations. Though the temperature of children will vary more than adults until they reach puberty, they would not typically be higher or lower.
  13. Prior to evaluating a client's respirations, the nurse is aware of factors that affect respirations. What are these factors?
    Those factors that increase respirations include exercise/exertion, stress, and higher environmental temperatures. Factors that may decrease a normal respiration rate would be lower environmental temperatures, some drugs, increased intracranial pressure as well as normal sleep.

    (pneumothorax, fear, fever, acid-base imbalance.)
  14. A nurse taking a client�s blood pressure thinks that a mistake was made. What are some common errors encountered when assessing the blood pressure?
    Hurrying on the part of the nurse may lead to one of the problem sources below. While a subconscious bias may lead to an error, it is unlikely that error would lead a nurse to �think� an error was made. So any of the following technique errors may be result from hurrying:

    • Bladder cuff not the correct size for patient.
    • Arm unsupported.
    • Insufficient rest before assessment.
    • Repeating assessment too quickly.
    • Cuff wrapped too loosely or unevenly.
    • Deflating cuff too quickly or too slowly.
    • Failure to use the same arm consistently.
    • Arm above heart level.
    • Assessment immediately after a meal, while client smokes, or is in pain.
    • Failure to identify auscultatory gap, which is the temporary disappearance of Karotkoff�s sounds which occurs particularly in hypertensive patients.

    (inflate it too rapidly or not high enough.)
  15. A client has had a mastectomy on the right side and an amputation of the left arm. How can the nurse take the client�s blood pressure?
    Either thigh that is not injured or diseased, e.g. hip, or that has not had inguinal lymph nodes removed can be used with an appropriate size blood pressure cuff instead of the arm. Karotkoff�s sounds can be heard in this case at the popliteal, tibial or dorsalis pedis pulse sites.
  16. Body heat that is lost when the nurse turns on the air conditioning at the client's request is what type of loss?


    Radiation
    Conduction
    Convection
    Vaporization
    Convection

    Objective: Describe factors that affect the vital signs and accurate measurement of them.

    Rationale: Convection is heat lost by air currents. Radiation is transfer of heat from one object to another. Conduction is transfer from a warmer molecule to one of lower temperature. Vaporization is lost from respiratory tract and from skin.
  17. When should the nurse take a client's temperature if the nurse wants to assess at the point of highest body temperature?


    0400 and 0600 (4 a.m. & 6 a.m.)
    1000 and 1400 (10 a.m. & 2 p.m.)
    1500 and 1800 (3 p.m. & 6 p.m.)
    2000 and 2400 (8 p.m. & midnight)
    2000 and 2400 (8 p.m. & midnight)

    Objective: Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.

    Rationale: Body temperatures change throughout the day, with the highest body temperature reached between 2000 and 2400 hours.
  18. What type of fever would the nurse document if the client had a wide range of temperature fluctuations over normal for a period of 24 hours?


    Intermittent
    Remittent
    Relapsing
    Constant
    Remittent

    Objective: Identify the variations in normal body temperature, pulse, respirations, and blood pressure that occur from infancy to old age.

    Rationale: A remittent fever widely fluctuates above normal over a 24-hour period. An intermittent fever rises above normal between periods of normal or subnormal temperatures. A relapsing fever is short febrile periods of a few days interspersed with 1-2 days of normal temperature. A constant fever remains above normal.
  19. What intervention would be most appropriate for a client with mild hypothermia?


    Applying blankets
    Applying an electronic hypothermia blanket
    Administering warmed intravenous fluids
    Providing a warm air temperature
    Applying blankets

    Objective: Describe appropriate nursing care for alterations in body temperature.

    Rationale: For mild hypothermia, rewarming the body by applying blankets is most appropriate. The others would be interventions for severe hypothermia.
  20. When assessing the pulse of a client on digitalis, what rate would the nurse expect as compared with the pulse prior to starting digitalis?

    It would be doubled.
    It would be slightly higher.
    It would not change.
    It would decrease.
    It would decrease.

    Objective: List the characteristics that should be included when assessing pulses.

    Rationale: Digitalis will decrease the heart rate, thereby decreasing the pulse.
  21. A nurse documents deep respirations on the client record. Which criteria were most likely assessed?


    A large amount of air inhaled and a small amount exhaled
    A large amount of air inhaled and a large amount exhaled
    A small amount of air inhaled and a small amount exhaled
    A small amount of air inhaled and a large amount exhaled
    A large amount of air inhaled and a large amount exhaled

    Objective: Describe the mechanics of breathing and the mechanisms that control respirations.

    Rationale: Deep respirations involve a large amount of inhaled and exhaled air. Shallow respirations involve a small amount of air exchange. Normal respirations entail easy effort, with about 500 ml of air on inhalation.
  22. A nurse needs to assess a client's pulse pressure. What is the correct procedure?

    Subtract the diastolic from the systolic blood pressure.
    Subtract the systolic from the diastolic blood pressure.
    Subtract the apical heart rate from the systolic blood pressure.
    Subtract the radial pulse from the diastolic blood pressure.
    Subtract the diastolic from the systolic blood pressure.

    Objective: Differentiate systolic from diastolic blood pressure.

    Rationale: The difference between the diastolic and the systolic pressures is called the pulse pressure.
  23. What are the most common sites for measuring body temperature? (Select all that apply.)

    Oral
    Temporal
    Tympanic membrane
    Rectal
    Axillary
    Capillary
    Oral

    Temporal

    Tympanic membrane

    Rectal

    Axillary

    Objective: Compare methods of measuring body temperature.

    Rationale: The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery.
  24. If a client has a temperature of 100 degrees Fahrenheit, calculate the finding in Celsius.
    37.8

    Objective: Describe appropriate nursing care for alterations in body temperature.

    Rationale: To calculate Celsius from Fahrenheit, deduct 32 from Fahrenheit reading and then multiply by the fraction 5/9.
  25. Which technique is best for assessing the respirations of a 3-year-old?

    Use a stethoscope and auscultate the lungs.
    Place one hand against the chest when counting.
    Observe the rise and fall of the abdomen.
    Tell the child you will check his breathing.
    Observe the rise and fall of the abdomen.

    Objective: Identify the components of a respiratory assessment.

    Rationale: A child who knows respirations are being counted may alter the respiratory effort or become upset. Observing the rise and fall of the abdomen without telling the child is the most accurate method.
  26. A home health nurse develops a plan for personal hygiene with the client and immediate family prior to discharge. Which home health hygienic plan best reflects the client's personal preferences?

    Bathe two times a week in the morning using a gentle shampoo and soap. Prefers that spouse participates in the bathing process. Is unable to stand throughout the length of the shower and will need time to sit down before the shower is over. Requires lotion on his skin.

    Shower on Monday and Thursday at bedtime. Requires an assistive device to facilitate rest during the shower. Shampoo hair one time a week. Oil the hair after shampooing and apply lotion to the skin. Examine the skin while applying lotion. Massage the back carefully. Perform active and passive range of motion while in the shower.

    Shower on Tuesday and Friday at 9 a.m. using shower chair in lower-level bathroom. Transfers using walker, with assist of spouse holding the right arm and the nurse partially supporting and balancing the client with a gait belt on the left side. Prefers the water to be warm but not hot, to use baby shampoo with conditioner on the hair and unscented gentle soap on the body.

    Prepare the shower before taking the client into the bathroom. The client's spouse will set supplies on the counter that are to be used for bathing. Client prefers a daily shower. Explain that this is not possible. Walk the client into the shower with the walker and spouse providing assistance. Allow the client to sit on a chair in the shower while washing self. Rewash those areas that require additional cleansing.
    Shower on Tuesday and Friday at 9 a.m. using shower chair in lower-level bathroom. Transfers using walker, with assist of spouse holding the right arm and the nurse partially supporting and balancing the client with a gait belt on the left side. Prefers the water to be warm but not hot, to use baby shampoo with conditioner on the hair and unscented gentle soap on the body.

    Objective: Describe hygienic care that nurses provide to clients.

    Rationale: A client's personal preferences should be followed as long as they are compatible with the client's health status and equipment available. None of the other answers contain the amount of detail present in Answer 3. The more personal detail that is included in a plan, the more prepared will be the nurse who actually makes the home visit.
  27. Which client is most likely to have hearing loss related to cerumen impaction?

    An older adult in a long-term care facility
    An older adult from home, now in the hospital for carpal tunnel surgery
    A 4-year-old with bilateral otitis media
    A 17-year-old with swimmer's ear
    An older adult in a long-term care facility

    Objective: Identify normal and abnormal assessment findings while providing hygiene care.

    Rationale: Older adults have the highest incidence of cerumen impaction. The incidence of cerumen impaction in older adults in the community, such as the client in Answer 2, is 35%. Older adults in institutions have an incidence greater than 35%.
  28. Bathing a client provides an excellent opportunity to assess the client's integument. Which finding indicates the need for referral to another health care professional?


    Flaky, rough skin in exposed areas
    Hirsutism of the chin
    Pitting edema of the ankles and feet
    Cheilosis - dry cracked lips
    Pitting edema of the ankles and feet

    Objective: Identify normal and abnormal assessment findings while providing hygiene care.

    Rationale: Nursing care usually will treat the conditions mentioned in Answers 1, 2, and 4, while the condition noted in Answer 3 can be caused by serious medical problems.
  29. A client has significant body odor. The best solution is:

    Apply deodorant
    Apply antiperspirant
    Cleanliness
    Apply talcum powder
    Cleanliness

    Objective: Identify factors influencing personal hygiene.

    Rationale: Deodorant and talcum powder disguise odors rather than rid the body of the odors. Antiperspirants reduce perspiration; they are applied only after the skin is cleaned.
  30. While supervising certified nursing assistants using a hydraulic lift to bathe a client in the bathtub, the nurse instructs them regarding a safety precaution after the nurse observes:

    The hydraulic chair being lifted above the level of the tub
    The client's legs being first lowered into the bathtub before the rest of the body
    The client being transported to the bathroom in a shower chair
    The hydraulic lift being lowered to tub level when the client is removed from the bathtub
    The hydraulic lift being lowered to tub level when the client is removed from the bathtub

    Objective: Explain specific ways in which nurses help hospitalized clients with hygiene.

    Rationale: All of the answers represent proper techniques except for Answer 4. When transferring clients to and from a hydraulic lift, it must be positioned at its lowest position, to prevent injury to the client or nurse.
  31. When cleaning the male genitalia, interventions are used to prevent infection. One such intervention is:

    Cleaning the scrotum before the penis
    Retracting the foreskin to remove smegma
    Washing the penis from the bottom to the glans
    Washing the buttocks first and then, with a fresh washcloth, washing the penis
    Retracting the foreskin to remove smegma

    Objective: Describe steps for identified hygienic-care procedures.

    Rationale: The scrotum is closer to the rectum, so it is washed after the penis. The glans is the cleanest area and is washed before other areas of the genitalia.
  32. An elderly, bedridden relative is returning home to die. Family members will take turns caring for the client. A nurse reviews care of the client, including hygiene and skin care. Which statement by a relative indicates that additional instruction is required?

    "The best time to use lotion on skin is just after bathing."
    "Cornstarch used in the axilla and groin absorbs excess moisture and odors."
    "Bathe less frequently when the skin or humidity is dry."
    "Use creams that contain lanolin to retain skin moisture."
    "Cornstarch used in the axilla and groin absorbs excess moisture and odors."

    Objective: Describe steps for identified hygienic-care procedures.

    Rationale: Answers 1, 3, and 4 are statements by relatives that indicate understanding of instructions. Cornstarch can break down into simpler compounds and promote bacterial growth.
  33. A client has reddened areas under the breasts. What should the nurse do after cleaning and drying the skin?

    Expose the areas to light
    Apply nonirritating powder lightly to the area
    Use lotion on the skin
    Apply deodorant to the area
    Apply nonirritating powder lightly to the area

    Objective: Describe steps for identified hygienic-care procedures.

    Rationale: The nurse should apply nonirritating powder lightly to the area. There is no evidence that the treatment in Answers 1, 3, and 4 benefit the skin irritation.
  34. A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention is to:

    Swab the oral cavity with a water-soaked sponge as needed.
    Swab the mouth every half-hour with lemon-glycerin swabs.
    Swab lips and mucus membranes with mineral oil.
    Swab the oral cavity with hydrogen peroxide, followed with water.
    Swab the oral cavity with a water-soaked sponge as needed.

    Objective: Identify normal and abnormal assessment findings while providing hygiene care.

    Rationale: The best intervention is to swab the oral cavity with a water-soaked sponge swab as needed. Answer 2 leads to further dryness of mucosa and changes in tooth enamel. Aspiration can initiate lipid pneumonia. Swabbing the oral cavity with hydrogen peroxide, followed with water, irritates healthy oral mucosa and may alter the microflora of the mouth.
  35. Before inserting a client's hearing aid, the nurse should:

    Turn the volume all the way down
    Remove the batteries
    Turn the volume all of the way up
    Soak the hearing aid in warm water to clean it
    Turn the volume all the way down

    Objective: Describe steps for removing, cleaning, and inserting hearing aids.

    Rationale: Cleaning the aid and removing batteries are done when the aid is removed and stored. Turning the volume all the way up could hurt the client. Hearing aids should not be submersed in water.
  36. The nurse positions the immobilized client to maintain the ability for normal movement and stability. This is accomplished when the nurse:

    Positions the joints in the flexed position to prevent contracture formation
    Positions the shoulders anterior to the hips to balance upper and lower body parts
    Performs range of motion with every position change to keep joints flexible
    Balances the body off the center of gravity to prevent skin breakdown
    Performs range of motion with every position change to keep joints flexible

    Objective: Describe four basic elements of normal movement.

    Rationale: When improperly positioned, joints flex into fixed positions and lose mobility. Properly aligned shoulders and hips fall into the same line of gravity. A properly balanced body is balanced at the center of gravity.
  37. teen in a full leg cast asks about preventing muscle mass loss in the cast. The best type of exercise the nurse can recommend is:

    Isotonic
    Isometric
    Isokinetic
    Aerobic
    Isometric

    Objective: Compare the effects of exercise and immobility on body systems.

    Rationale: The client requires a form of exercise that does not require joint movement but does allow a change in muscle tension. Isotonic, isokinetic, and aerobic forms of exercises require active movement.
  38. On the fifth postoperative day after major abdominal surgery, the nurse evaluates a client for the effects of immobility. The nurse notes that the care plan was successful when the client states:

    "I'm not using as much pain medication as I did yesterday."
    "I'm still dizzy when I get up, but it is getting better."
    "I am ready to eat something besides Jell-O and broth."
    "I hardly even think about smoking anymore."
    "I am ready to eat something besides Jell-O and broth."

    Objective: Compare the effects of exercise and immobility on body systems.

    Rationale: The nurse is evaluating for signs that the client has suffered no effects of immobility. Answer 2 is an effect of immobility. Other findings are present, but not related to immobility.
  39. An employee health nurse teaches a body mechanics class. While demonstrating proper lifting techniques, the nurse says:

    "Put the object to be lifted 12 inches from your feet."
    "Lift no more than 50% of your body weight plus 5 kilograms."
    "Lift with flexed knees and hyperextended back."
    "Lift with the large muscles of the legs, abdomen, and arms."
    "Lift with the large muscles of the legs, abdomen, and arms."

    Objective: Use safe practices when positioning, moving, lifting, and ambulating clients

    Rationale: Body mechanics used for lifting indicate that the closer an object is to the one lifting, the greater the stability. Flexed knees and back help prevent injuries, as long as one does not lift more than one is able. Each person's limit is individual.
  40. A position that puts an unconscious client at greatest risk for aspirating secretions is:

    Supine
    Lateral
    Sims'
    Prone
    Supine

    Objective: Use safe practices when positioning, moving, lifting, and ambulating clients.

    Rationale: Supine position puts client at greatest risk for aspirating secretions. Lateral, Sims', and prone positions allow secretions to drain from the mouth.
  41. Which of the following describes a client with a nursing diagnosis of Activity Intolerance III?

    Fatigued at rest
    Able to climb one flight of stairs slowly without stopping
    Unable to climb one flight of stairs without stopping
    Able to walk one city block without stopping
    Unable to climb one flight of stairs without stopping

    Objective: Unable to climb one flight of stairs without stopping is Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.

    • Rationale: Activity Intolerance III. Fatigued at rest is Level IV.
    • Able to climb one flight of stairs slowly without stopping is Level II. Able to walk one city block without stopping is Level II.
  42. Two nurses plan to move a client with weakness into a wheelchair. As they prepare to make the transfer, one of the nurses correctly instructs the client to:

    Use the IV pole as a lever when rising from the bed
    Push up from the bed using her arms on the count of three
    Hold on to the side rails facing the bottom of the bed before standing
    Put feet behind the nurses' feet
    Push up from the bed using her arms on the count of three

    Objective: Use safe practices when positioning, moving, lifting, and ambulating clients.

    Rationale: The client should push up from the bed using her arms on the count of three. The IV pole is unstable, and may roll away from the client. A client should face in the direction in which she is moving. The nurses' feet need to be in front of the client's.
  43. A nurse evaluating the performance of an unlicensed assistant corrects a client's position. Which client requires repositioning?

    A client in a Fowler's position, with the head of the bed raised 75 degrees, a large pillow placed under the head, and plantar flexion of the feet
    A client in a Dorsal Recumbent position, with the head flat, a small pillow under the lumbar curve, and sandbags placed lateral to the trochanter of the femur
    A client in a prone position, with the head turned to the side, a small pillow under the abdomen, and the lower legs supported on a pillow with feet extended
    A client in a right lateral position, with the arms in front of the body, the upper arm supported with a pillow, and the shoulders and hips aligned with one another
    A client in a Fowler's position, with the head of the bed raised 75 degrees, a large pillow placed under the head, and plantar flexion of the feet

    Objective: Identify factors influencing a person's body alignment and activity.

    Rationale: A client in a Fowler's position, with the head of the bed raised 75 degrees, a large pillow placed under the head, and plantar flexion of the feet, requires repositioning. Answers 2, 3, and 4 are positioned correctly.
  44. Which of the following techniques imposes the greatest stress on the nurse's back?

    Lifting with the large muscles of the legs
    Helping clients ambulate
    Turning immobilized clients in bed
    Transferring clients in and out of bed
    Transferring clients in and out of bed

    Objective: Use safe practices when positioning, moving, lifting, and ambulating clients.

    Rationale: All of the answers may impose a stress on the nurse's back. Answer 4 imposes the greatest risk because of the potential for twisting and working in a small place.
  45. A nurse is assessing a client's range of motion. An abnormality is detected when:

    The head hyperextends back 10 degrees from an upright position
    The arm abducts 180 degrees laterally from the side of the body to the side and above the head
    The elbow supinates 90 degrees
    The thumb flexes 45 degrees toward the fifth finger
    The thumb flexes 45 degrees toward the fifth finger

    Objective: Apply a variety of movement interventions and therapies to improve physical health, mobility, strength, balance, mood and cognition.

    Rationale: An abnormality is detected when the thumb flexes 45 degrees toward the fifth finger. Answers 1, 2, and 3 are not abnormalities.

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