Practice Test for PN - NCLEX: 1. A mother reported that her son is throwing up each time she feeds him. What would be the best assessment question the nurse would ask? a. Did you warm up the formula? b. What kind of formula did you give him? c. Does your son feel hungry each time he throws up? d. Does your son have a jelly-like stool? Answer: D – jelly-like stool is an indication of GI problem. 2. Rosemarie is 24 years old, G1P0, admitted with a diagnosis of Multiple Sclerosis. The nurse observes indications of positive response from treatments and signs that the patient is recovering from the disease by which of the following assessment data? a. Less frequent mood swings. b. Able to wiggle toes and move fingers. c. Worsening urinary incontinence. d. Ambulates with a more stable gait. Answer: D – Multiple Sclerosis temporarily affects both sensory and motor. Being able to walk with stable gait is a sign that the motor function is returning to normal. 3. Rolland works in the construction site and sustains head injury when a small piece of metal dropped on his head. As a result of the accident, he experiences brief loss of conciousness. He was admitted in the medical unit for further investigation and sub dural hematoma is suspected. Important nursing care provided for Mr. T includes: a. Side lying b. Semi fowler’s c. High fowler’s d. Flat Answer: B – due to possible increased ICP, semi-fowlers’ position is appropriate to promote venous drainage and decreases ICP. 4. Ron is 4-year-old child being discharge to home after an uneventful tonsillectomy. The nurse would suggest that the appropriate car seat for the child is a. the rear-facing seat. b. the front facing seat. c. the booster seat with car seat belt. d. the back seat. Answer: C – booster car seat is appropriate for a bigger child. 5. Mr. Dubin is admitted with a diagnosis of severe anemia. He was ordered two units of packed cells. Should Mr. Dubin develops hemolytic transfusion reaction, nurse will immediately stop the transfusion and then a. run the IV NS. b. send the remaining blood to the lab. c. monitor the vital signs. d. collect urine specimen to be sent to the lab.. Answer: A – Normal Saline is compatible with blood transfusion. The physician must be informed after running the NS. 6. A patient with rheumatoid arthritis complains to the nurse about her back pain and said, “I want a bed that is similar to what I have at home.” What would be an appropriate nursing response? a. “I will massage your back to ease up the pain.” b. “I will ask the physician to order analgesic for you.” c. “I will refer you to the occupational therapist.” d. Ask the husband how the patient sleeps at home. Answer: D – assessment is the first step to be taken by the nurse. 7. Bonnie and 4-year-old daughter moved to a new apartment. Two days after the move the girl became ill and was taken to the ER. Lead poisoning was suspected (plumbism). Lead was possibly inhaled from the fresh paint in the apartment. The nurse is aware that lead can fatally affect the a. heart. b. brain. c. skin. d. kidney. Answer: B – lead is inhaled and deposited in bone marrow and blocks the formation of RBC but it can seriously affect the CNS. 8. After a craniotomy for the removal of hematoma sustained in a fall, the patient is returned to the recovery room. The nurse places the child in a semi-fowler’s position to a. increase venous drainage and prevent accumulation of fluid. b. promote lung expansion and improve oxygenation. c. decrease pressure on the diaphragm and increase thoracic pressure. d. promote oxygenation and keeps the child more alert.. Answer: A –this position utilizes gravity to drain fluid from the head and prevent fluid accumulation. Case Study: Francis is a 48-year-old female, patient transferred in from a community hospital admitted there on 2/4/06 with lower abdominal pain, which shows free air on X-ray. For few days prior to admission, she was taking Tylenol #3 for abdominal and feet pain which causes her constipation. Her past medical history includes blindness both eyes; IDDM since age 8; failing cadaveric kidney —had renal transplant in ’88; developed skin cancer from Cyclosporin; has HTN, Cholesterol, CAD-MI in ’98; PVD-bilateral feet ulcer; recurrent UTI’s. In May 2001, she went for R forearm AV fistula placement. However, due to uncontrolled HTN, the AV fistula has a very weak bruit, which cannot be used for hemodialysis. Due to intestinal obstruction (from Tylenol #3—constipation), on April 12, 2002, she had resection of the sigmoid and a temporary colostomy was put in. Qestions 9. During admission, Francis’ blood sugar was noted to be 15 mmos/L. Important treatment for Francis would include: a. IV fluids b. Potassium c. NPH insulin d. Kayexalate Answer: A – IV fluids are given to combat dehydration. Glucose has an osmotic diuretic effect causing polyuria. 10. An immediate danger to confront Francis secondary to her elevated blood sugar level is a. albumin is negative. b. dehydration and impending shock. c. hyperglycemia. d. renal failure. Answer: B – glucose has an osmotic diuretic effect causing polyuria. 15. The type of insulin expected to be ordered by the physician to treat Francis elevated blood sugar would be: a. NPH b. Regular c. Protamine Zinc d. Globulin Answer: B - Short acting or regular insulin usually reaches the blood within 30 minutes after injection, peaks in 2 to 4 hours and stays in the bloodstream for 6 to 8 hours. Because of its short and predictable peak action, regular insulin is the insulin routinely used for intravenous administration. 16. Francis went into diabetic coma. The nurse may observe which one as typical manifestation (s) of ketoacidosis: a. Slow, bounding pulse. b. Deep, rapid respirations. c. Diaphoresis, cold clammy skin. d. Dilated pupil, hypotension. Answer: B—The body’s effort to get rid of the acid through breathing. 17. Francis’ serum K⁺ level is 3.8 mEq/L. Potassium chloride 40 mEq has been prescribed to be added to the first liter of IV fluid. The nurse should a. Question the physician’s order because the K⁺ level is within the normal limit. b. Question the physician’s order because the K⁺ level is above the normal range. c. Recognize that potassium is transferred into the cellular compartment during insulin therapy. d. Recognize that potassium is being given to correct the existing hyponatremia. Answer: C—ketoacidosis means high blood glucose. Insulin is expected to be administered to lower the blood glucose level. At the same token, insulin transport potassium back to the cell. Thus, potassium IV is usually given prophylactically with insulin. 18. The PN assigned to Francis knows the importance of rotating insulin injection sites. Injection should be given in any one spot more often than every two weeks. Site rotation is important to prevent or combat which of the following complications? a. Abnormal tissue changes which may result in poor absorption of the injected insulin. b. Rapid absorption of insulin due to tissue sensitivity. c. Formation of glucagon promotes a rise in blood sugar, thereby, producing hyperglycemia. d. Increased blood glucocorticoids raise blood sugar by stimulating the conversion of fat and protein into glucose. Answer: A -- To avoid tissue atropy or hypertrophy, patients should be taught to avoid injecting insulin in the same site each time. Instead, they should be advised to give the injection in the same general area. For example, giving a "before breakfast" injection in the abdomen and "before supper" injection in the leg each day will give similar blood glucose results. 19. Which of the following drugs prescribed to Francis contributes to hyperglycemia? a. Prednisone b. Zantac c. Tylenol #3 d. Antibiotic Answer: A – Prednisone is steroid that increases blood sugar. 20. The importance of monitoring blood sugar, activity level, and insulin doses is to a. adjust the activity level based on the blood sugar level. b. adjust the diet and insulin doses as the activity level increases or decreases. c. adjust the diet and activity level based on the blood sugar level. d. adjust the insulin doses based on the sugar level in the urine. Answer: B- If a patient injects too much insulin, exercises too much in relation to carbohydrate consumed, or does not eat enough or eat at the appropriate times, the blood glucose level can fall low enough to cause hypoglycemia. 23. Insulin or oral hypoglycemic agents, diet and exercise are the most effective ways in treating diabetes. Oral hypoglycemic agents may be used for patients with: a. Ketosis b. Obesity c. Type I DM d. Some insulin production Answer: D – oral hypoglycemics may be helpful when some functioning of the beta cells exists, as in type