Nclex for Rn

NCLEX for RN - Leadership and Management (1-5)

NCLEX for RN about Leadership and Management

1. A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice?

a) a task approach method is used to provide care to clientsb) managed care concepts and tools are used in providing client carec) an RN leads nursing personnel in providing care to a group of clientsd) a single RN is responsible for providing nursing care to a group of clients

2. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant?

a) ignore the resistanceb) exert coercion with the nursing assistantc) provide a positive reward system for the nursing assistantd) confront the nursing assistant to encourage verbalization of feelings regarding the change

3. A nurse is giving a report to a nursing assistant who will be caring for a client who has hand restraints. The nurse instructs the nursing assistant to assess the skin integrity of the restrained hands every:

a) 2 hoursb) 3 hoursc) 4 hoursd) 30 minutes

4. Fibrinolysin and desoxyribonuclease (Elase) is prescribed to treat a skin ulcer, and the nurse is observing a nursing student perform the treatment. The nurse intervenes if the nursing student is observed doing which of the following?

a) applies a thin layer of medicationb) cleans the wound with a sterile solution

c) places petrolatum gauze over the fibrinolysin and desoxyribonucleased) applies a thick layer of medication and covers with a dry sterile dressings

5. A nursing student is caring for a client with a brain attack (stroke) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit?

a) tells the client to scan the environmentb) approaches the client from the unaffected sidec) places the bedside articles on the affected sided) moves the commode and cahir to the affected side

NCLEX for RN - Leadership and Management: ANSWERS AND RATIONALE

1) C- In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option A identifies functional nursing. Option B identifies a component of case management. Option D identifies primary nursing.

2) D- Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option A will not address the problem. Option B may produce additional resistance. Option C may provide a temporary solution to the resistance but will not address the concern

3) D- The nurse should instruct the nursing assistant to assess restraints and skin integrity every 30 minutes. Agency guidelines regarding the use of restraints should always be followed.

4) D- The wound should be cleansed with a sterile solution and gently patted dry. A thin layer of fibrinolysin and desoxyribonuclease (Elase) is applied and covered with petrolatum gauze. If a dry powder preparation is used, for best effects, the solution should be prepared just before use.

5) B- Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client’s risk for injury. The nurse’s role is to refocus

1 | P a g e

the client’s attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client from the affected side to increase awareness further.

6. A nursing instructor asks the nursing student to describe the definition of a critical path. Which of the following statements, if made by the student, indicates a need for further understanding regarding critical paths?

a) they are developed through the collaborative efforts of all members of the health care teamb) they provide an effective way of monitoring care and for reducing or controlling the length of hospital stay for the clientc) they are developed based on appropriate standards of cared) they are nursing care plans and use the steps of the nursing process

7. A community health nurse is working with a disaster relief following a tornado. The nurse's goal for the community is to prevent as much injury and death as possible from the uncontrollable event. Finding safe housing for survivors, providing support to families, organizing counseling, and securing physical care when needed all examples of which type of prevention?

a) primary level of preventionb) secondary level of preventionc) tertiary level of prevention d) aggregate care prevention

8. The nurse manager is planning to implement a change in the nursing unit from team nursing to primary nursing. The nurse anticipates that there will be resistance to the change during the change process. The primary technique that the nurse would use in implementing this change is which of the following?

a) introduce the change graduallyb) confront the individuals involved in the change processc) use coercion to implement the changed) manipulate the participants in the change process

9. A nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) are primarily characteristic of preicteric phase?

a) right upper quadrant painb) fatigue, anorexia and nauseac) jaundice, dark-colored urine, and clay-colored stoolsd) pruritus

10. A nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for the arrival of the client?

a) prepare a private room at the end of the hallwayb) place a sign on the door that indicates that visitors are limited to 60-minute visitsc) assign one primary nurse to care for the client during the hospital stayd) place a linen bag outside of the client's room for discarding linens after morning care

NCLEX for RN - Leadership and Management: ANSWERS AND RATIONALE

6) D- Use the process of elimination and knowledge regarding the definition and purpose of critical paths to direct you to option D. Note the strategic words in the question, a need for further understanding. These words indicate a negative event query and ask you to select an option that is incorrect. If you had difficulty with this question, review critical paths.

7) C- Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from occurring, and secondary prevention focuses on reducing the intensity and duration of a crisis during the crisis itself. There is no known aggregate care prevention level.

2 | P a g e

8) A- The primary technique that can used to handle resistance to change during the change process is to introduce the change gradually. Confrontation is an important strategy used to meet resistance when it occurs. Coercion is another strategy that can be used to decrease resistance to change but is not always a successful technique for managing resistance. Manipulation usually involves a covert action, such as leaving out pieces of vital information that the participants might receive negatively. It is not the best method of implementing a change.

9) B- In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. Options A, C, and D are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundicedecreases, the color of urine and stool return to normal, and the client’s appetite improves.

10) A- The client with an internal cervical radiation implant should be placed in a private room at the end of the hall because this location provides less of a chance of exposure of radiation to others. The client’s room should be marked with appropriate signs that indicate the presence of radiation. Visitors should be limited to 30-minute visits. Nurses assigned to this client should be rotated so that one nurse is not consistently caring for the client and exposing him or herself to excess amounts of radiation. All linens should be kept in the client’s room until the implant is removed in case the implant has dislodged and needs to be located.

is side effect from occurringd) losing your hair is less traumatic than losing breast

2. Aling Nena is being assessed of her nutritional status. She weigh 100 lbs and is 5'8 ft. tall. Her assessment would include the following except:

a) a diet historyb) anthropometric measurementsc) food preferencesd) serum protein

3. Which nursing action would best attain the goal of

providing and promoting coping for Aling Nena?

a) telling Aling Nena for her strengths and progressb) planning experienced for her that are conclusivec) helping her to identify her problems and solutionsd) giving her information on how to handle her problems

Try to read the latest type of cancer, it might be included in the exam --> Mesothelioma Cancer

NCLEX Review Questions on Cancer:ANSWERS AND RATIONALE

1) B- the drug can cause alopecia or hair loss but the hair will grow back after treatment. The nurse can advise the patient to wear a wig or other head accessories for coverage. The patient should buy the wig before hair falls out.5-fluoroucacil or 5-FU is an antineoplastic drug that used for the cancers of the colon, rectum, breast, stomach and pancreas.

The adverse side effects of this drug are: Photosensitivity - advise to avoid prolonged exposure to sunlight and to use highly protective sunlight to prevent inflammatory erythematous dermatitis

advise patient she cannot get pregnant or breastfeed while under medication because of its toxic effect

advise patient to discontinue drug and report to physician if diarrhea occurs as it is a sign of toxicity

Mouth sores (stomatitis) - apply topical anesthetics for comfort, advise oral hygiene to prevent infection of the denuded oral mucosa

Nausea, vomiting, and anorexia - give antiemetic before administration

Leukopenia, anemia, agranulocytosis - avoid exposure to infection

Scaling of the skin, pruritus, desquamative rash of hands and feet, and nail changes - reversible aftermedication, can be treated with pyridoxine 50-150 mg for 7 days

Thrombocytopenia - avoid IM injections when platelet count goes below 50,000

if crystals form in the drug - redissolve by warming solution

3 | P a g e

do not use cloudy solution, do not refrigirate, protect from sunlight, discard unused portion after 1 hour

use plastic IV bags if to be infused by intravenous route as the drug is more stable in plastic than glass

2) C- although inquiry about food preferences is history taking, it is not used in the standard nutritional status assessment of the patient.The information gained during nutritional status assessment are: Anthropometric measurements: height, weight, body mass index (BMI), circumferential measurements

Physical examination - clinical signs and symptoms such as pallor, dry skin, brittle hair, mouth sores

Diet history - 24 hours diet recall to assess the quality and quantity of food intake

Diagnostic tests: hemoglobin, hematocrit, transferring, serum protein, total lymphocyte count, nitrogen balance, d-xylose absorption test, creatinine excretion, serum levels

3) C

NCLEX Review Questions on Cancer

4. The nurse evaluates that zofran (ondansetron) is effective in a client undergoing chemotherapy if which of the following is observed?

a) urine output is 1,500 ml/dayb) the client can tolerate mechanically soft dietc) the client's anxiety is relievedd) the client was able to sleep

5. A client with cancer of the colon who is receiving chemotherapy tells a nurse that some foods on the metal tray taste bitter. The nurse would try ti limit which of the following foods that is most likely to cause this taste for the client?

a) cantaloupeb) potatoesc) beefd) custard

6. A client suspected of having lung tumor is scheduled for a computerized tomography (CT) scan with dye injection. A nurse tells the client that

a) the test may be painfulb) the dye injected may cause a warm, flushing

sensationc) fluids will be restricted following the testd) the test takes approximately 2 hours

7. Which of the following is a nursing responsibility for a client undergoing external radiation therapy?

a) wear gown, gloves and maskb) observe time, distance, and shieldingc) provide the client adequate rest and schedule activityd) place the client in isolation for few days

8. Who among these clients is at high risk to develop testicular cancer?

a) the client has undescended testes at birthb) the client has human papilloma virusc) the client has recurrent urinary tract infectiond) the client is uncircumcised

9. A nursing assistant is taking care of a patient who had undergone liver biopsy. When should the registered nurse intervene?

a) when the nursing assistant monitors the patient's vital signs every 15 minutes for the 1st two hours after the procedureb) when the nursing assistant tells the patient to remain in bed for several hoursc) when the nursing assistant positions the patient on the left sided) when the nursing assistant checks the biopsy site for bleeding

10. Which of the following is a risk factor to cancer of the colon?

a) diabetes mellitusb) peptic ulcerc) abdominal herniad) high fat, high calorie diet

Try to read the latest type of cancer, it might be included in the exam --> Mesothelioma Cancer

NCLEX Review Questions on Cancer: ANSWERS AND RATIONALE

4) B- zofran is antiemetic. The drug is effective if the client is no longer experiencing nausea and vomiting. Therefore, the client can already tolerate food.

5) C

4 | P a g e

http://www.online-mesothelioma-cancer.com/

- meat is perceived as bitter by clients with cancer

6) B- iodinated contrast medium causes warm, flushing sensation as it is injected.

7) C- fatigue is a side effect of external radiation therapy. Answers A, B, and D are practiced in internal radiation therapy.

8) A- history of undescended testes at birth is strongly linked with testicular cancer.

9) C- the client should be turned to the right side after liver biopsy, not on the left side. Turning the client on the right side will apply pressure on the site and will prevent bleeding.

10) D- high fat, high protein and high carbohydrate diet increase the risk of cancer in the colon.

11. Which of the following should the nurse assess prior to administration of cisplatin?

a) hydrationb) hemoglobinc) weightd) ECG

12. The client is receiving internal radiation therapy. What is the appropriate nursing action to minimize radiation contamination?

a) put the soiled linens in double bagb) keep clients things close to her bedsidec) always wear gloves when entering the client's roomd) minimize contact with the client

13. A client is suspected of having pheochromocytoma. Which of the following signs and symptoms would help support this diagnosis?

a) abdominal painb) anuriac) hypertensiond) weight gain

14. Before uterine radioactive implant is inserted, which of the following physician's orders does the nurse expect?

a) administer analgesicb) administer sedativec) administer enemad) administer antibiotic

15. The nurse is admitting a patient with jaundice, due to pancreatic cancer. Which of the following would the nurse give highest priority?

a) body imageb) nutritionc) skin integrityd) anticipatory grieving

NCLEX Review Questions on Cancer: ANSWERS AND RATIONALE

11) A- cisplatin, a neoplastic agent is nephrotoxic. The client should be adequately hydrated before administration of the drug.

12) D- Each contact with the client undergoing internal radiation therapy should last for 5 minutes only, a total of 30 minutes in an 8-hour shift, to minimize radiation contamination. The nurse should wear dosimeter badge to measure radiation exposure.

13) C- pheochromocytoma is a tumor in the adrenal medulla that stimulates increased secretion of catecholamines (epinephrine/norepinephrine). This causes hypertension.

14) C- during uterine radioactive implant, the client should be on bedrest. Defecation should be avoided during treatment to prevent dislodgement of the implant. Therefore, enema is usually ordered by the physician before the treatment.

15) C- give priority to physiologic before psychosocial needs. Jaundice causes severe pruritus. Therefore, maintaining skin integrity is a priority.

16. After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/cu.mm. What term should the nurse use to describe this low platelet count?

17. Which of the following should the nurse include when providing health teachings for

5 | P a g e

patients at risk of developingprostatic cancer?

a) participate in smoking cessation programb) perform monthly self-testicular examinationc) maintain daily walking exercised) undergo monthly digital rectal examination

18. Which of the following questions should the nurse ask in a client who is at risk for breast cancer?

a) does your family have a history of multiple gestation?b) does your family have a history of ovarian cancer?c) does your family have a history of early menopause?d) does your family have a history of late menarche?

19. Which of the following client history increases risk for anorectal cancer?

a) chronic constipationb) high fiber dietc) alcohol abused) chronic inflammatory bowel disease

20. A client will be for uterine radium implant. Which of the following statement when made by the client indicates the need for further teaching?

a) my sister is coming to stay with me today after implant insertionb) I will be in bed for the duration of the treatmentc) I will have a foley catheter in placed) I will have enema before the procedure

ANSWERS AND RATIONALE

16) thrombocytopenia- the normal thrombocyte count is 150,000 to 450,000/ cu.mm.

17) A- smoking increases risk for prostatic cancer. Choice B is done to detect cancer of the testes. Choice D, digital rectal examination is recommended annually, not monthly.

18) B- history of cancer of the reproductive system (cancer of the uterus, cervix, and ovaries) increase risk for breast cancer.

19) D

- chronic inflammatory bowel disease are primarily associated with anorectal cancer.

20) A- the client on internal radiation therapy should be on isolation to prevent radiation contamination of other people.

NCLEX Review about Cardiac Nursing (1-5)NCLEX Review about Cardiac Nursing

1. Who among these clients with congenital heart diseases should be cared for first by the nurse?

a) the child with coarctation of aorta with elevated blood pressure in the upper extremityb) the child with tetralogy of Fallot with clubbing of fingers and elevated red blood cellsc) the child with ductus arteriosus who experiences fatigue after feedingd) the child with ventricular septal defect who murmurs on auscultation of the chest

2. The child had been diagnosed to have rheumatic fever. Which of the following does the nurse expect to assess in the child?

a) painless nodules in bony prominenceb) decreased antistreptoysin O (ASO) titerc) desquamation of the skin on the tips of finger and toesd) high-grade fever that spikes in the morning

3. The nurse teaches the mother on lanoxin (digoxin) administration to an infant. Which of the following statements when made by the mother indicates that the teaching is effective?

a) I can give the medication to my child as long as his heart rate is above to 70 beats per minuteb) I will give the medication one hour before or 2 hours after feedingc) I will mix the medication with the milk feedingd) I will mix the medication with mashed fruits

4. Which of the following is most important to monitor in the client after surgery for abdominal aortic aneurysm?

a) intake and output measurement every shiftb) blood pressure every 4 hoursc) body temperature every 4 hoursd) abdominal girth

5. The client experiences intermittent claudification. Which of the following should be included in the nursing care planof the client to promote comfort and general condition?

6 | P a g e

a) elevate the legs when sitting or lying supineb) apply warm compresses to the legsc) encourage progressive exercisesd) apply elastic bandage on the legs

NCLEX Review about Cardiac Nursing:ANSWERS AND RATIONALE

1) C - the client is experiencing hypoxia. Need for oxygenation take priority. Choices A, B and D are expected findings.

2) A- subcutaneous nodules are painless swellings. Other signs and symptoms of rheumatic fever are: migrating polyarthritis, increased ASO titer, increased ESR, arthralgia, fever. Choice C describes kawasaki disease.

3) B- digoxin should be given on empty stomach. This ensures adequate absorption of the medication. In an infant, digoxin is not given if the apical pulse is below 90-110 bpm. For older children, if the apical pulse is below 70 bpm, the drug is also withheld.

4) D- internal bleeding will cause accumulation of blood within the abdominal cavity. Increase in abdominal girth is an accurate indicator of this complication.

5) C- progressive exercises, especially walking promote arterial collateral circulation (intermittent claudification is a sign of arterial insufficiency).

NCLEX Review about Cardiac Nursing

6. The client undergone cardiac catheterization. His blanket is soaked with blood. What is the best initial nursing action?

a) notify the physicianb) monitor vital signsc) assess where the site of bleeding is, and apply pressure on that sited) transport the client back to the cardiac catheterization laboratory

7. A client with heart disease is on low-fat diet. A

nurse evaluates that the client understands the diet if the client states that a food item to avoid is:

a) plumsb) cherriesc) avocadod) peaches

8. Which of the following best shows effective coping of the client after myocardial infarction?

a) the patient plans to return to work in 2 to 3 daysb) the patient ask her husband to bathe and dress herc) the patient states that she needs to commit to lifelong lifestyle changes

9. A client complains of chest pain. What should be the nurse,s priority action?

a) check vital signsb) notify physicianc) let the client lie down and check if the pain is relieved by restd) administer sublingual nitroglycerine

10. Which of the following assessment data are the usual manifestations of a client with mitral valve stenosis?

a) dependent edemab) dyspnea on exertion and fatiguec) distended neck veind) enlarged liver


6) C- puncture site for catheter insertion may be in the brachial or femoral vein/artery. In case of bleeding, the initial nursing action is to assess and apply pressure to the site.

7) C

8) D- the client accepts that a lifestyle change is lifetime. This is to promote health and well-being of the

7 | P a g e

person.- avocado is high in fats

9) A- gather additional information about the client's condition first. Next action is to notify the physician. (Assessment is done before implementation).

10) B- mitral valve stenosis leads to left-sided heart failure. This produces pulmonary manifestations ("left lung"). Left heart affectation results to lung manifestations like dyspnea on exertion.11. Which of the following are non-modifiable risk factors for cardiovascular disorders?

a) age and genderb) obesity and hypertensionc) stress and smokingd) caffeine and alcohol

12. Which of the following laboratory findings is expected in a patient with myocardial infarction?

a) elevated troponin levelsb) elevated SGPT (ALT) levelsc) elevated LDH 2 levelsd) elevated CK-MM levels

13. Which of the following is a manifestation of negligence when a client with heart disease is in labor

a) the client is in lithotomy position with her feet in stirrupsb) the client's vital signs are monitored closelyc) the client receives oxygen therapy through face maskd) the client has a patent IV access line

14. The client had undergone cardiac catheterization using femoral artery. Which of the following should be included in the nursing care plan of the client?

a) keep the affected leg immobile and in extended position for few hoursb) apply warm compress at the puncture sitec) allow the client to ambulate once vital signs are stabled) maintain NPO status until gag reflex returns

15. After cardiac catheterization, the client experiences chest pain. Which of the following is the best initial nursing action?

a) bring the patient back to the cardiac catheterization laboratoryb) administer analgesicc) take an ECGd) assist the client to ambulate


11) A- age and gender are non-modifiable or unavoidable risk factors for cardiovascular disorders. The other options are modifiable risk factors.

12) A- elevated troponin levels are the best indicator of M.I. Troponin I of 1.5 mg/ml, Troponin T greater than 0.1 to 0.2 are supportive of MI.

13) A- lithotomy position increases cardiac workload. The client should be placed in semi-fowler's position to decrease cardiac workload and promote oxygenation.

14) A- after cardiac catheterization involving femoral artery, the affected leg should be kept immobile and in extended position for few hours. This is to prevent bleeding and to promote adequate circulation in the leg.

15) - assessment is the first nursing action. ECG may reveal dysrhythmias which cause chest pain after cardiac catheterization. Gather adequate information before implementation.


16. Which of the following signs and symptoms indicate pacemaker failure?

8 | P a g e

a) excessive thirstb) prolonged hiccupsc) flushing of the skind) increased urine output

17. The client is diagnosed to have acute myocardial infarction. He has a nursing diagnosis of decreased cardiac output. This is secondary to

a) chest painb) circulatory overloadc) electrolytes imbalanced) ventricular dysrhythmias

18. Which of the following physician's order should the nurse question when preparing a client who will undergo artery bypass graft within an hour?

a) potassium chloride per slow IV dripb) calcium channel blockerc) digoxind) prophylactic antibiotic

19. The client has been diagnosed to have right-sided congestive heart failure (RSCHF). Which of the following signs and symptoms does the nurse expect to observe in the client?

a) shortness of breathb) ascitesc) rales in the lung apicesd) pink-tinged, frothy sputum

20. The client with cardiac disorder experiences hypokalemia. Which of the following ECG changes would the client have?

a) elevated ST segmentb) presence of U-wavec) tall T-waved) prolonged QRS complex

NCLEX Review about Cardiac NursingANSWERS AND RATIONALE

16) B

- prolonged hiccups indicate pacemaker failure. Other signs and symptoms of pacemaker failure are dysrhythmias, dizziness, faintness, chest pain, shortness of breath, increase or decrease in apical rate.

17) D- ventricular dysrhythmias are the primary causes of decreased cardiac output with myocardial infarction.

18) C- digoxin increases force of cardiac contractility and therefore it increases cardiac workload.

19) B- RSCHF is characterized by venous backup, like ascites. Choices A, C, and D are manifestations of a client with Left-sided CHF.

20) B- hypokalemia is characterized by presence of U-wave, depressed ST segment, and short T-wave.


21. The client with congestive heart failure develops cardiac tamponade. Which of the following signs and symptoms would the nurse assess?

a) distant or muffled heart soundsb) hypertensionc) bradycardiad) increased urine output

22. The nurse is giving health teachings to several clients. Which among these clients is at risk for coronary artery diseases?

a) the client who works in the department storeb) the client who smokes cigarettec) the client who had her menarche at age 12 years oldd) the client whose serum cholesterol level is 180 mg/dL

23. Which of the following questions is most important to ask in a client with congestive heart failure who has jugular vein distention?

9 | P a g e

a) at what time do you go to sleep during the night?b) how many pillows do you use when lying down?c) what do you drink before going to sleep?d) how many hours of night sleep do you have?

24. The drug of choice to control premature ventricular contractions, ventricular tachycardia, or ventricular fibrillation is

a) quinidineb) procainamidec) bretyliumd) lidocaine

25. Which of the following situations in a client with myocardial infarction (MI) should be given highest priority?

a) the client complains of palpitationsb) the client's BP is 170/95c) the client has premature ventricular contractions of 4 multifocals/mind) the client serum enzyme studies are elevated


21) A- cardiac tamponade involves accumulation of fluid in the pericardial sac. It restricts ventricular filling and decreases cardiac output. It is characterized by distant, muffled sound, distended neck veins, and diminished or absent pulse (Beck's triad).

22) B- cigarette smoking is one of the most common risks of CAD (Coronary artery disease).

23) B- orthopnea, which is difficulty in breathing when in lying position relieved by upright position, is a sign of progressive cardiac disorder.

24) D- lidocaine is the first line of drug to control PVC's, VT, VF. Lidocaine exerts anesthetic effect on the

heart thus decreasing myocardial irritability.

25) B- elevated BP increases afterload, and therefore increases cardiac workload. This leads to increased myocardial oxygen demand.


26. The client has coronary artery disease (CAD). Which of the following statements when made by the client indicates that he understands the health instructions?

a) I need to avoid carbohydratesb) I need to avoid working in cold weatherc) I need to avoid exercised) I need to avoid fruits

27. A client had a second myocardial infarction episode. The nurse determines the precipitating factor when the client says

a) I use my nicoderm patch, so I can quit smokingb) I go for a walk in the park, each morning during summerc) I get tired when I climb a flight of stairsd) I include fruits and vegetables in my diet

28. The client has been diagnosed to have chronic congestive heart failure (CHF). What is the earliest sign that indicates recurrence of CHF?

a) dyspneab) syncopal episodec) tachycardiad) elevated blood pressure

29. Which of the following is a prominent signs and symptoms in a client with COA (coarctation of aorta)?

a) elevated BP in both lower extremitiesb) diminished femoral pulsec) cyanosisd) machinery murmurs

30. Which of the following signs and symptoms indicate pacemaker failure?

10 | P a g e

a) increased pulse rateb) decreased pulse rate of 60 beats per minutec) flushing of the skind) elevated body temperature


26. B- working in cold weather precipitates coronary artery spasm. This reduces myocardial tissue perfusion and oxygenation. Therefore the client with CAD should avoid working in cold weather.

27) A- nicotine causes vasoconstriction. Nicoderm patch is contraindicated for clients with history of M.I.

28) A- dyspnea is the earliest sign that indicates recurrence of CHF

29) B- coarctation of aorta is characterized by the following signs and symptoms:

hypertension in the higher extremities

hypotension in the lower extremities

diminished pulse in the lower extremities

30) B- bradycardia is a sign of pacemaker failure. Other signs and symptoms of pacemaker failure are as follows: dizziness, faintness, shortness of breath, prolonged hiccups.


31. Left-sided congestive heart failure is most often associated with which of the following manifestations?

a) dyspneab) distended neck veinc) hepatomegalyd) pedal edema

32. A client with chest pain is admitted to the emergency department. He states that his chest pain was not relieved after taking 3 nitroglycerine tablets at home. Which of the following is the best initial nursing action?

a) administer the prescribed analgesicb) give nitroglycerine sublinguallyc) monitor blood pressured) monitor ECG

33. After cardiac catheterization, which of the following findings should the nurse report to the physician?

a) pain on the groin when changing positionsb) the client denies tingling sensation in the extremityc) the client verbalizes that she experienced flushing sensation during the procedured) the toenail blanches on compression and pinkish color returns after 1 to 3 seconds

34. After cardiac catheterization that involves femoral artery, which of the following actions by the RN needs intervention by the charge nurse?

a) the RN monitors the client's vital signsb) the RN applies small ice pack over the puncture sitec) the RN elevates the head of the bed to sitting position as requested by the clientd) the RN immobilizes the affected extremity in extension

35. An elderly client who had suffered a severe heart attack says to the nurse, "I have a living will and my children do not agree with what I have decided. I hope you nurses and doctors will abide by my wishes." Which of these responses by the nurse is best?

a) your wishes are the most importantb) do you expect your children to be here when you have to make decisions?c) you and your children should really decide togetherd) it's always best to reconsider your decisions


11 | P a g e

31) A- left-sided congestive heart failure is characterized by signs and symptoms due to: a. pulmonary edema ("left" - "lung"), b. cellular hypoxia, c. RAAS activation --> hypertension and hypokalemia.Choices B, C, D are signs and symptoms of right-sided CHF.

32) A- relief of chest pain is a priority in myocardial infarction. Pain increases cardiac workload and may lead to shock. Morphine sulfate is the drug of choice.

33) A- pain in the groin after cardiac catheterization may indicate hematoma at the site. This indicates bleeding at the site and compression of blood vessels by the hematoma may occur. his in turn, may cause circulatory impairment in the area.

34) C- avoid acute hip flexion after cardiac catheterization involving the femoral artery to prevent circulatory impairment. HOB may be elevated only up to 30 deg for the first 6 to 8 hours

35) A- the client's wishes are primary considerations in living will.


36. The following are manifestations of left-sided congestive heart failure. Select all that apply

a) hypertensionb) dependent edemac) hypokalemiad) paroxysmal nocturnal dyspneae) non-productive coughf) pink-tinged, frothy sputumg) ascites

37. Which of the following health teachings should be included when caring for a client with angina pectoris?

a) limit cigarette smokingb) do not go out during cold weather

c) take sublingual nitroglycerine every 5 minutes until chest pain subsidesd) keep nitroglycerine in a clear plastic container

38. A client has dual chamber pacemaker, which of the following is true about the pacemaker?

a) it provides atrial firingb) it provides ventricular firingc) it provides both atrial and ventricular firingd) it provides alternate atrial and ventricular firing

39. Which of the following is a characteristic manifestation of the patient with cardiac tamponade?

a) increased pulse rateb) rapid respirationc) increased body temperatured) distended neck vein

40. Which of the following findings in a client who had undergone cardiac catheterization needs immediate follow-up?

a) bleeding on dressingb) capillary refill of more than 3 secondsc) feeling of warmth and thirstd) drowsiness


36) A, C, D, E, F- these are signs and symptoms of left-sided CHF. Signs and symptoms of left-sided CHF are due to pulmonary edema, cellular hypoxia and activation of renin-angiotensin- aldosterone system (RAAS).

37) B- precipitating events to chest pain in angina pectoris include exposure to cold, exertion, eating a large meal, and strong emotions.

38) C- a dual chamber pacemaker provides both atrial and ventricular firing.

12 | P a g e

39) D- cardiac tamponade, an accumulation of blood in the pericardial sac is characterized by Beck's triad signs and symptoms which are as follows: distended neck vein, muffled heart sounds and diminished or absent pulse.

40) B- capillary refill of more than 3 seconds indicates circulatory impairment, and needs immediate follow-up. Normal capillary refill time is 1 to 2 seconds.


41. The nurse is completing the admission assessment on the client with chest pain. Which of the following statements by the client indicates the priority modifiable risk factor for coronary artery disease?

a) I have been told that I have a high cholesterol levelb) my father died of a heart attack at age 48c) I have been under a lot of stress at work latelyd) I know I am overweight and have to do something about it

42. The client with chest pain was diagnosed with myocardial infarction and is now ready to be discharged. The nurse is reviewing discharge instructions. Which statement if made by the client indicates the highest priority teaching need?

a) I am going to try and cut down on smokingb) from now on I am going to eat mainly fruits and vegetablesc) I plan to take up jogging when I go homed) I plan to work half days for a while

43. A nurse is providing care to a client immediately after the insertion of a cardiac pacemaker. Which action is most important for the nurse to do first?

a) observe the incision site for signs of local infectionb) arrange for the client to have a post-insertion x-rayc) monitor vital signs every 15 minutes until stabled) encourage client to get out of bed with assistance

44. The home care nurse calls the wife of the client

with chronic heart disease who is coughing frothy, white secretions and became confused during the night. Which question is most important for the nurse to ask?

a) did your husband eat breakfast this morning?b) what did your husband do yesterday?c) where did your husband sleep last night?d) are your husband's ankles swollen?

45. The nurse is completing the admission assessment form on the client with chronic heart disease. Which of the following, if noted by the nurse, indicates a priority symptom of left-sided heart failure?

a) distended neck veinb) edema of the lower extremitiesc) weight gain of 10 pounds in the last monthd) crackles in the lungs


41) A- high serum cholesterol level is one of the most common modifiable risk factor for coronary artery disease.

42) C- walking is the best exercise for post-MI clients undergoing cardiac rehabilitation. Jogging may not be well-tolerated by the client. Therefore, choice C indicates knowledge deficit of the client and these requires further teaching.

43) C- close monitoring of the client after insertion of cardiac pacemaker especially the vital signs is very essential. Changes in the vital signs indicate occurrence of complications.

44) C- orthopnea, like sleeping in a couch indicates progressive heart failure like CHF (congestive heart failure) and pulmonary edema.

13 | P a g e

45) D- left-sided congestive heart failure may lead to pulmonary edema. Signs and symptoms pertaining to the lungs are characteristic of left-sided congestive heart failure.Choices A, B, and C are due to venous back-up which characterize right-sided congestive heart failure.

CLEX Review about Cardiac Nursing

46. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a) weight lossb) flat neck and hand veinsc) an increase in blood pressured) a decreased central venous pressure (CVP)

47. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?. 46. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a) weight lossb) flat neck and hand veinsc) an increase in blood pressured) a decreased central venous pressure (CVP)

47. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The

nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?

a) dry skinb) decreased urinary outputc) hyperactive bowel soundsd) increased specific gravity of the urine

48. A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T bloodspecimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a:

a) normal levelb) low value that indicates possible gastritisc) level that indicates a myocardial infarctiond) level that indicates the presence of possible angina

49. A client with atrial fibrillation who is receiving maintainance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders?

a) adding a dose of heparin sodiumb) holding the next dose of warfarinc) increasing the next dose of warfarind) administering the next dose of warfarin

50. A client recently diagnosed with a myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 ml/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain blood pressure. on entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that hte client is most likely

a) hematomab) systemic infectionc) electrolyte overloadd) circulatory overload

14 | P a g e


46) C- assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options A, B and D identify signs noted in deficient fluid volume.

47) C- hyperactive bowel sounds indicate hyponatremia. Options A, B and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urinEdit Postse would be noted. Dry skin occurs in deficient fluid volume.

48) C- troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins T are released to the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction.

49) B- the normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.

50) D- circulatory (fluid overload) is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure would also increase. Hematoma is characterized by ecchymosis, swelling and leakage at the IV insertion site, and hard and painful lumps at the site. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting,

backaches, and tachycardia. Signs of electrolyte imbalance depend on the specific electrolyte.

51. A clinic nurse has provided home care instructions o the client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instructions?

a) it is best that I rest lying on my side to promote blood return to the heartb) I need to avoid excessive weight gain to prevent increased demands on my heartc) I need to try to avoid stressful situations because stress increases the workload of the heartd) During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection

52. A nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

a) I should drink adequate fluids and increase my intake of high-fiber foodsb) I should maintain a low-calorie diet to prevent any weight gainc) I should lower my blood volume by limiting fluidsd) I should increase my sodium intake during pregnancy

53. A clinic nurse reviews the record of a child just seen by a physician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

a) pallorb) hyperactivityc) exercise intoleranced) gastrointestinal disturbances

54. A nurse has provided home care instructions to the mother of a child who is being discharged following cardiac surgery. Which statement made by the mother indicates a need for further instructions?

a) a balance of rest and exercise is important

15 | P a g e

b) I can apply lotion or powder to the incision if it is itchyc) activities in which my child could fall need to be avoided for 2 to 4 weeksd) large crowds of people need to avoided for at least 2 weeks following surgery

55. A nurse provides home care instructions to the parents of a child with congestive heart failure (CHF) regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by the parent, indicates the need for further instructions?

a) I will not mix the medication with foodb) If more than one dose is missed, I will call the physicianc) I will take the child's pulse before administering the medicationd) if the child vomits after medication administration, I will repeat the dose


51) D- to avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Stress causes increased heart workload, and the client should be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting should be done by lying on the side to promote blood return.

52) A- constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. Therefore, high-fiber foods are important. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients, so adequate fluid intake and high-fiber foods are important. Sodium should be restricted somewhat, as prescribed by the physician, because excess sodium will cause an overload to the circulating blood volume and contribute to cardiac complications.

53) C- The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time. Pallor may be noted but is not specific to this type of disorder alone. Options B and D are not related to this disorder.

54) B- The mother should be instructed that lotions and powders should not be applied to the incision site. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options A, C and D are accurate instructions regarding home care after cardiac surgery.

55) D- The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options A, B and C are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

56. A nurse is caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse assesses the infant for which early sign of CHF?

a) coughb) pallorc) tachycardiad) slow and shallow breathing

57. A physician has prescribed oxygen as needed for an infant with congestive heart failure (CHF). In which situation should the nurse administer the oxygen to the infant?

a) during sleepb) when changing the infant's diapersc) when the mother is holding the infantd) when drawing blood for electrolyte testing

58. A nurse is monitoring an infant with congestive

16 | P a g e

heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and the need to call the physician?

a) bradypneab) diaphoresisc) decreased blood pressured) a weight gain of 1 lb in 1 day

59. The nurse is preparing the client with chronic heart failure for discharge to home. Which statement if made by the client indicates the highest priority teaching need?

a) I will get out of bed slowly in the morningb) I plan to rest as much as possible when I get homec) I will let my health care provider know if I gain 4 pounds or more in two daysd) I will have to cut down on potato chips

60. A 22-year old adult has cholesterol blood test done at screening clinic sponsored by a local health club. The nurse volunteering at the screening teaches the client that diet and exercise should be used as health measures to keep thetotal cholesterol below:

a) 80 mg/dLb) 200 mg/dLc) 250 mg/dLd) 300 mg/dLNCLEX REVIEW ABOUT CARDIAC NURSING:ANSWERS AND RATIONALE

56) C- The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign.

57) DCrying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options A,B, C are not likely to produce crying in the infant.

58) DA weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the physician. Tachypnea and an increased blood pressure would occur with fluid accumulation. Diaphoresis is a sign of CHF but is not specific to fluid accumulation, and usually occurs with exertional activities.

59) B- the client with chronic heart failure should have a balance between rest and activity. Therefore, choice B indicates knowledge deficit of the client and this indicates need for further teaching.

60) B

- The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Options C and D are elevated values and place the client at risk for cardiovascular disease. Although option A is a low cholesterol level, option B identifies the realistic value to assist in preventing cardiovascular disease.

NCLEX Review on Delegation and Prioritization Questions 46-50NCLEX Review on Delegation and Prioritization Questions

46. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?

a) a primiparous client in the active stage of laborb) a multiparous client who was admitted for induction of laborc) a client who is not contracting, but has suspected premature ruptured) a client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

47. A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to:

a) turn on the apnea and cardiorespiratory monitorsb) connect the resuscitation bag to the oxygen outletc) set up the intravenous line with 5% dextrose in

17 | P a g e

waterd) set the radiant warmer control temperature at 36.5C (97.6F)

48. A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, the priority nursing diagnosis would be risk for:

a) infectionb) aspirationc) activity intoleranced) altered growth and development

49. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:

a) notify the physicianb) turn the child to the sidec) maintain an NPO statusd) administer the prescribed antiemetic

50. The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster?

a) the nurse who never had rubeolab) the nurse who never had mumpsc) the nurse who never had chickenpoxd) the nurse who never had german measles

NCLEX REVIEW ON DELEGATION AND PRIORITIZATION QUESTIONS: ANSWERS AND RATIONALE

46) D- Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options A, B, and C because these clients conditions represent stable ones.

47) B- The highest priority on admission to the nursery for a newborn with a low Apgar scores is the airway, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they

are of lower priority. The newborn infant will be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

48) A- Initial care of the newborn with myelomeningocele involves prevention of infection. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents and to prevent tearing or breakdown of the skin integrity at the site. Any opening in the sac greatly increases the risk of infection of the central nervous system. Activity intolerance and risk for aspiration would not be priority problems with this defect. Risk for altered growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period.

49) B- After tonsillectomy, if bleeding occurs, the nurse turns the child to the side and then notifies the physician. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turnthe child to the side.

50) C- Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Options A, B, and D are unrelated to the herpes zoster virus.

NCLEX Review on Delegation and Prioritization Questions

41. A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the order, and a blood specimen is drawn from the client for typing and cross-matching. The nurse receives a telephone call from the blood bank and is informed that he unit of blood is ready for administration. Arrange the actions in order of priority that the nurse should take to administer the blood. (Letter A is the first and letter F is the last action.)

a) hang the bag of bloodb) obtain the unit of blood from the bank

18 | P a g e

c) ensure that an informed consent has been signedd) verify the physician's order for the blood transfusione) insert an 18 or 19-gauge IV catheter into the clientf) ask a licensed nurse to assist in confirming blood compatibility and verifying client identity.

42. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following?

a) open the airwayb) give the client oxygenc) start chest compressionsd) ventilate with a mouth-to-mask device

43. A nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange in order of priority the steps of adult CPR. (Letter A is the first step and letter F is the last step.)

a) initiate breathingb) open the client's airwayc) determine breathlessnessd) perform chest compressionse) check for a pulse at the carotid arteryf) determine unconsciousness by shaking the client and asking "Are you OK?"

44. A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client?

a) assess the patency of the airwayb) check tubes or drains for patencyc) check the dressing to assess for bleedingd) assess the vital signs to compare with preoperative measurements.

45. A nurse is caring for a pregnant client with preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses for preeclampsia to eclampsia, the nurse's first action should be to:

a) administer oxygen by face maskb) clear and maintain an open airwayc) administer magnesium sulfate intravenouslyd) assess the blood pressure and fetal heart rate

NCLEX Review on Delegation and Prioritization QuestionsANSWERS AND RATIONALE

41) F, D, B, A, C, E- The nurse would first verify the physician’s order for the blood transfusion and ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge intravenous needle is inserted into the client. Blood has a thicker and stickier consistency than intravenous solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. Next, the blood is obtained from the blood bank, once the nurse is sure that the client has been informed and has an adequate access for administering the blood. Once the blood has been obtained, two registered nurses, or one registered and a licensed practical nurse (depending on agency policy), must together check the label on the blood product against the client’s identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. The nurse should measure vital signs and assess lung sounds and then hang the transfusion.

42) A- The next nursing action would be to open the airway. Ventilation cannot be initiated unless the airway is opened. Chest compressions are started after opening the airway and initiating ventilation. Oxygen may be helpful at some point, but the airway is opened first.

43) D, B, C, F, E, A- The sequence for basic CPR for health care providers is as follows. After determining unconsciousness, the airway is opened and breathlessness is determined. Next, the health care provider delivers effective breaths that produce a

19 | P a g e

visible rise in the chest, followed by assessing the carotid artery for presence of a pulse. In the absence of any pulse, chest compressions are provided at an adequate rate and depth that will allow adequate chest recoil, with minimal interruptions in chest compressions.

44) A- The first action of the nurse is to assess the patency of the airway and respiratory function. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. If the airway is not patent, the nurse must take immediate measures for the survival of the client. Options B, C, and D are all nursing actions that should be performed after a patent airway has been established.

45) B- The immediate care during a seizure (eclampsia) is to ensure a patent airway. Options A, C, and D are actions that follow or are implemented after the seizure has ceased.NCLEX Review on Delegation and Prioritization Questions

46. A labor and delivery room nurse has just received report on four clients. The nurse should assess which client first?

a) a primiparous client in the active stage of laborb) a multiparous client who was admitted for induction of laborc) a client who is not contracting, but has suspected premature ruptured) a client who has just received an IV loading dose of magnesium sulfate to stop preterm labor

47. A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn infant with Apgar scores of 1 and 4. In planning for admission of this infant, the nurse's highest priority should be to:

a) turn on the apnea and cardiorespiratory monitorsb) connect the resuscitation bag to the oxygen outletc) set up the intravenous line with 5% dextrose in waterd) set the radiant warmer control temperature at 36.5C (97.6F)

48. A nurse is caring for a newborn infant with spina bifida (myelomeningocele) who is scheduled for surgical closure of the sac. In the preoperative period, the priority nursing diagnosis would be risk for:

a) infectionb) aspirationc) activity intoleranced) altered growth and development

49. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:

a) notify the physicianb) turn the child to the sidec) maintain an NPO statusd) administer the prescribed antiemetic

50. The nurse manager is planning the clinical assignments for the day and avoids assigning which staff member to the client with herpes zoster?

a) the nurse who never had rubeolab) the nurse who never had mumpsc) the nurse who never had chickenpoxd) the nurse who never had german measles

NCLEX REVIEW ON DELEGATION AND PRIORITIZATION QUESTIONS: ANSWERS AND RATIONALE

46) D- Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should be seen before the clients in options A, B, and C because these clients conditions represent stable ones.

47) B- The highest priority on admission to the nursery for a newborn with a low Apgar scores is the airway,

20 | P a g e

which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower priority. The newborn infant will be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

48) A- Initial care of the newborn with myelomeningocele involves prevention of infection. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents and to prevent tearing or breakdown of the skin integrity at the site. Any opening in the sac greatly increases the risk of infection of the central nervous system. Activity intolerance and risk for aspiration would not be priority problems with this defect. Risk for altered growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period.

49) B- After tonsillectomy, if bleeding occurs, the nurse turns the child to the side and then notifies the physician. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turnthe child to the side.

50) C- Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster. Options A, B, and D are unrelated to the herpes zoster virus.


36. The nurse is giving a bed bath to an assigned client when a nursing assistant enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following?

a) finish the bed bath and then administer the pain medication to the other clientb) ask the nursing assistant to find out when the last pain medication was given to the clientc) ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is completed) cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

37. A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to preform the Allen's Test on the client. Arrange in order of priority the steps for performing Allen's test. (Letter A is the first step and letter F is the last step.

a) document the findingsb) explain the procedure to the clientc) release pressure from the ulnar arteryd) apply pressure over the ulnar and radial arteriese) ask the client to open and close the hand repeatedlyf) assess the color of the extremity distal to the pressure point

38. A nurse is monitoring a client receiving parenteral nutrition. The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. Arrange the actions that the nurse would take in order of priority (Letter A is the first action and letter F is the last action).

a) administer oxygenb) contact the physicianc) document the occurrenced) take the client's vital signse) clamp the intravenous catheterf) position the client in left trendelenburg position

39. A client has 1L bag of 5% dextrose in 0.9% sodium chloride hung at 3PM. The nurse making rounds at 3:45PM finds that the client is complaining of pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 ml remaining. The nurse should take which of the following action first?

21 | P a g e

a) call the physicianb) slow the IV infusionc) sit the client up in bedd) remove the IV catheter

40. The nurse determines that he client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next?

a) remove the IV lineb) run normal saline at a keep vein open ratec) run a solution of 5% dextrose in waterd) obtain a culture of the tip of the catheter device removed from the client

NCLEX Review on Delegation and Prioritization Questions:ANSWERS AND RATIONALE

36) D- The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options A and C delay the administration of medication to the client in pain. Option B is not a responsibility of the nursing assistant.

37) F, A, D, B, C, E- The Allen’s test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client’s ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If

pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings.

38) D, C, F, E, A, B- If air embolism is suspected, the nurse would first clamp the intravenous catheter to prevent the embolism from traveling through the heart to the pulmonary system. The nurse would next place the client in a left side-lying position with the head lower than the feet (to trap air in right side of the heart). The nurse would notify the physician and administer oxygen as prescribed. The nurse would monitor the client closely and take the client’s vital signs. Finally, the nurse documents the occurrence.

39) B- The client’s symptoms are compatible with circulatory overload. This may be verified by noting that 600 mL has infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if necessary. The nurse also notifies the physician immediately. The IV catheter is not removed; it may be needed once the complication has been resolved.

40) B- If the nurse suspects a transfusion reaction, the nurse stops the transfusion and infuses normal saline at a keep vein open rate pending further physician orders. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The nurse would not discontinue the IV line because then there would be no IV access route. Obtaining a culture of the tip of the catheter device removed from the client is incorrect. First, the catheter should not be removed. Second, cultures are performed when infection, not transfusion reaction, is suspected. Normal saline is the solution of choice over solutions containing dextrose because saline does not cause red blood cells to clump.


1. A nurse from medical-surgical unit is asked to work

22 | P a g e

on the orthopedic unit. The medical-surgical nurse has noorthopedic nursing experience. Which client should be assigned to the medical-surgical nurse?

a) a client with a cast for a fractured femur and who has numbness and discoloration of the toesb) a client with balanced skeletal traction and who needs assistance with morning carec) a client who had an above-the-knee amputation yesterday and has a temperature of 101.4Fd) a client who had a total hip replacement 2 days ago and needs blood glucose monitoring

2. The nurse plans care for a client undergoing a colposcopy. Which of the following actions should the nurse take first?

a) discuss the client's fear regarding potential cervical cancerb) assist with silver nitrate application to the cervix to control bleedingc) provide instructions regarding douching and sexual relationsd) administer pain medication

3. A nurse is caring for four clients and is preparing to do her initial rounds. Which client should the nurse assess first?

a) a client with diabetes being discharged todayb) a client with tracheostomy and copious secretionsc) a client scheduled for physical therapy this morningd) a client with a pressure ulcer that needs dressing change

4. A nurse enters a room and finds a client lying on the floor. Which action should the nurse perform first?

a) call for help to get the client back in bedb) establish whether the client is responsivec) assist the client back to bedd) ask the client what happened

5. A nurse preceptor is working with a new nurse and notes that the new nurse is reluctant to delegate tasks to members of the care team. The nurse preceptor recognizes that this reluctance most likely

is due to:

a) role modeling behaviors of the preceptorb) the philosophy of the new nurse's school of nursingc) the orientation provided to the new nursed) lack of trust in the team members


1) D- a nurse from medical-surgical unit floated to the orthopedic unit should be given clients with stable condition, and those whose care are similar to her training and experience. A client who is 2-day postop is more likely to be on stable condition. And the medical-surgical unit nurse is competent in monitoring blood glucose.

2) B- the priority nursing action when caring for a client who will undergo colposcopy is to assist in controlling potential bleeding by applying silver nitrate to the cervix.

3) B- a patient with problem of the airway should be given highest priority. ABC is a priority.

4) B- assessing for responsiveness is the first nursing action when performing CPR.

5) D- lack of trust is the most common reason for reluctance in delegating tasks among members of the team.


6. A nurse is working in an emergency department and receives a client after a radiologic incident. Which task is a priority for the nurse to do first?

a) decontaminate the client's clothing

23 | P a g e

b) decontaminate an open wound on the client's thighc) decontaminate the examination room the client is placed ind) save the client's vomitus for analysis by the radiation safety staff

7. The nurse plans care for a client in the post-anesthesia care unit. Which assessment should the nurse make first?

a) respiratory statusb) level of consciousnessc) level of paind) reflexes and movement of extremities

8. A nurse in the clinic is reviewing the diet of a 28-year old female who reports several months of intermittent abdominal pain, abdominal bloating, and flatulence. Which is a priority for the nurse to counsel the client to avoid in her diet?

a) fiberb) broccolic) yogurtd) simple carbohydrates

9. A nurse is developing the care plan for a client after bariatric surgery for morbid obesity. The nurse includes which of the following on the care plan as the priority complication to prevent?

a) painb) wound infectionc) depressiond) thrombophlebitis

10. A client presents to the emergency room with dyspnea, chest pain, and syncope. The nurse assesses the client and notes that the client is pale and diaphoretic with blood pressure 94/60, respiration 32. The client is anxious, fearing death. Which action should the nurse take first?

a) administer pain medicationb) administer IV fluidsc) administer dopamined) administer oxygen per nasal cannula


6) B- decontaminating an open wound is the first priority when caring for a client after a radiologic incident. This minimizes absorption of radiation in the client's body.

7) A- assessing respiratory status is the first priority when caring for a client in the post-anensthesia care unit. ABC is a priority.

8) B- broccoli is gas forming. This should be avoided in clients experiencing flatulence.

9) B- wound infection is the most common complication among obese clients who had undergone surgery. This is due to poor blood supply in the adipose tissues. Therefore, there is decreased oxygen supply and diminished supply of protective cells in the areas.

10) D- promotion of adequate oxygenation is most vital to life. Therefore, this should be given highest priority by the nurse for a client with dyspnea, chest pain, and syncope.


11. A nurse in a long term facility is planning care for an elderly client with confusion. Which action should the nurse take first?

a) sit the client in a geriatric chair with an activityb) apply a vest restraint when the client is in a chairc) apply bilateral wrist restraints when the client is in bedd) have a staff member sit with the client at all times

12. The nurse is providing care in the emergency department to the client with chest pain. Which action is most important for the nurse to do first?

24 | P a g e

a) perform venipuncture and start an IV lineb) administer oxygen via nasal cannulac) administer morphine sulfate intravenouslyd) start lidocaine (xylocaine) infusion

13. A nurse arrives on the scene of a multi-motor vehicle accident. The nurse determines that which of the following clients should be seen first?

a) A 48 year old male who is pale, diaphoretic and reporting chest pain and shortness of breathb) a 16 year old male with ecchymosis, pain, and swelling of the right armc) a 42 year old female who has a laceration on the forehead and is reporting neck and shoulder paind) an 8 year old child who is crying hysterically and reports abdominal pain

14. A child reports to the camp nurse's office after stepping on a bee. The child has pain, erythema, and edema of the lower aspect of the left foot. As the nurse is observing the foot, the child says, "I feel like my throat is getting tight." The first action the nurse should take is:

a) assess the child's airway and breathingb) call 911 and request an ambulancec) administer subcutaneous epinephrined) remove the stinger from the foot

15. A nurse is working on a poison control hot-line and gets a call from a mother who reports her child has apparently taken part of a bottle of adult acetaminophen capsules. The priority action for the nurse to take first is:

a) tell the mother to position the child lying down on her sideb) tell the mother to dial 911 and request an ambulancec) have the mother give the child a glass of milkd) instruct the mother on how to administer syrup of ipecac


11) Apromotion of safety and providing diversional activities are priority nursing care for confused elderly clients. Application of restraints should be the last resort. Having a staff member sit with the client at all times is not necessary, unless the client is at risk to injury.

12) B- administration of oxygen is a priority nursing action in a client with chest pain. The primary reason for chest pain is inadequate myocardial oxygenation.

13) A- the client with problem of the airway and who has unstable condition should be given highest priority. Priority ABC.

14) A- the situation indicates that the child is having anaphylactic reaction. The first action by the nurse is to assess airway and breathing. Priority assessment is ABC.

15) D- acetaminophen is non-corrosive. Therefore, inducing vomiting by administering syrup of ipecac is appropriate management in case of acetaminophen overdose or poisoning.


16. A nurse receives a 10-month old child with a fracture of the left femur on the pediatric unit. Which action is important for the nurse to take first?

a) call for a social worker to meet with the familyb) check the child's blood pressure, then pulse, respiration, and temperaturec) administer pain medicationd) speak with the parents about how the fracture occurred

17. A nurse on the cardiac unit is caring for four clients and is preparing to do initial rounds. Which client should the nurse assess first?

25 | P a g e

a) a client scheduled for cardiac ultrasound this morningb) a client with syncope being discharged todayc) a client with chronic bronchitis on nasal oxygend) a client with a diabetic foot ulcer that needs a dressing change

18. A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first?

a) determine level of consciousnessb) push the call button for helpc) turn the client face up to assessd) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician

19. A nurse is working on the night shift with a nursing assistant. The nursing assistant comes to the nurse stating that the other nurse working on the unit is not assessing a client with abdominal pain despite multiple requests. Which of the following actions by the nurse is best?

a) ask the other nurse if she needs any helpb) assess the client, and let the other nurse know what should be donec) ask the client if he is satisfied with his cared) contact the nursing supervisor to address the situation

20. The nurse is reviewing immunizations with the caregiver of a 72 year old client with a history of cerebral vasculardisease. The caregiver learns that which immunization is a priority for the client?

a) hepatitis A vaccineb) lyme disease vaccinec) hepatitis B vaccined) pneumococccal vaccine


16) D- in case of injury especially among children, it is very important that the nurse should first assess possible

abuse. Abuse is one of the reporting responsibilities of the nurse.

17) C- a client with problem of the airway should be attended first. ABC is a priority.

18) A- assessing level of consciousness is the first action when dealing with a situation where the client might have had a fall or when preparing to do CPR (cardio-pulmonary resuscitation).

19) D- the RN should use proper channel of communication. The nursing supervisor is responsible for the actions of the different members of the nursing team.

20) Dpneumococcal vaccine is a priority immunization for the elderly, especially those with chronic illness. It is administered every 5 years.


21. A nurse delegates administration of an enema to a nursing assistant. The nurse should intervene if the nursing assistant:

a) advances the catheter 4 inches into the anal canalb) hangs the enema bag 12 to 18 inches above the anusc) lubricates 4 to 5 inches of the catheter tipd) positions the client on the right side with head slightly elevated

22. A nurse is reviewing with a nursing assistant the care assignment for a client. Which of the following statements if made by the nurse regarding care of a client with crutches is most appropriate?

a) the client needs to ambulate with crutches and a two-point gaitb) ambulate the client without weight bearing every 4 hours the length of the hall and backc) ask the client if she understands how to use a two-point gait, if not, please explain it to the client

26 | P a g e

d) make sure the client does not bend the elbows when using the crutches

23. The home care nurse has four phone calls to answer. Which phone call should the home care nurse respond to first?

a) a client who received chemotherapy yesterday and is reporting nausea and vomitingb) a client who was discharged two days ago with a urinary catheter after a transurethral prostactemomy and is reporting pink-tinged urinec) a client with schizophrenia who says that the police has surrounded the housed) the wife of a client with chronic heart disease who reports her husband is coughing frothy, white secretions and became confused during the night

24. A nurse arrives on the scene of an apartment fire. Which of the following clients does the nurse attend to first?

a) a 3-year old child who cannot find her parents and is reporting a headacheb) a 48-year old male who has burns on both hands and reports severe painc) an 18-year old male who jumped from a second story window and is reporting severe arm paind) a 28-year old woman who has burns on the face and neck and reports difficulty swallowing

25. A female college student reports to the student health center very distressed after waking up in a male student's restroom and not remembering what happened to the night before. The first action the nurse should take is:

a) obtain a rape kitb) ask the client if she thinks she was rapedc) place the client in an examining room and leave her while she puts on a gownd) provide a quiet, private area to use for initial assessment of the client


21) D- the appropriate position of the client during enema administration is left lateral position to facilitate flow of solution by gravity. Therefore, the action of the CNA in choices no. 4 needs to be corrected.

22) B- when delegating task, the nurse should provide complete, concrete and specific directions.

23) D- the situation indicates development of pulmonary edema in the client with chronic heart disease. This serious complication is a priority.

24) D- burns on the face and neck involves obstruction of airway due to smoke inhalation. Airway is a priority.

25) D- this situation indicates possible rape of the client. Providing psychosocial support and ensuring privacy for initial assessment of the client is most appropriate initial action.


26. A nurse recently started working in a hospital that employs unlicensed assistant personnel (UAP). Which of the following are essential to effective delegation?

a) give the UAP written instructions for assignmentsb) make frequent walking rounds to assess clientsc) delegate tasks based on the experience of the UAPd) take frequent mini-reports from the UAPe) have the UAP repeat instructionsf) explain unexpected outcomes of delegated tasks to the UAP

27. A nurse is teaching a class regarding lead poisoning in children to student nurses. The nursing students learn to target which priority group of children for screening?

a) those with sickle cell anemiab) those who live in homes built in the 1960's

27 | P a g e

c) those who live in low-income familiesd) adolescents living in the inner city

28. A nurse is attending an In-service training class on delegation. The nurse learns that proper delegation can involve which of the following? Select all that apply

a) giving authorityb) delegating nursing processc) delegating tasksd) delegating accountabilitye) delegating responsibilityf) giving orders

29. When developing the plan of care for a client with suicidal ideation, which of the following would the nurse anticipate as the priority?

a)Self-esteemb)Sleepc)Hygiened)Safety

30. A client in early labor is receiving oxytocin. When observing late decelerations in the fetal heart rate, the nurse should first:

a) Administer oxygenb) Place her on her left sidec) Check the blood pressured) Discontinue the oxytocin infusion


26) A, B, C, D, E, F- all of these aspects are essential fro effective delegation.

27) C- lead poisoning is common in old houses (built in 1950's), and in places with unsanitary conditions including soil, dust, vehicles using leaded gas. These factors are common among low-income families.

28) A, C, and E- proper delegation involves giving authority, delegating tasks, and delegating responsibility. Nursing process, accountability and giving orders are to be done by the RN, and not to be delegated.

29) D- for the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although self-esteem, sleep and hygiene are common areas that require intervention for a client with suicidal ideation, ensuring the client’s safety is the most immediate and serious concern.

30) D- the infusion should be stopped because it is placing the fetus in danger.


31. A nurse employed in an emergency department is assigned to triage clients arriving to the emergency room for treatment on the evening shift. The nurse should assign highest priority to which of the following clients?

a) a client complaining of muscle aches, a headache, and malaiseb) a client who twisted her ankle when she fell while rollerbladingc) a client with a minor laceration on the index finger sustained while cutting an eggplantd) a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

32. The RN is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?

a) a client requiring colostomy irrigationb) a client receiving continuous tube feedingsc) a client who requires urine specimen collectionsd) a client with difficulty swallowing foods and fluids

33. The RN employed in a long-term care facility is planning assignments for the clients on a nursing

28 | P a g e

unit. The RNneeds to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse?

a) the client who requires a bed bathb) an older client requiring frequent ambulationc) a client who requires a 24-hour urine collectiond) a client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

34. The RN has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the RN plan to care for first?

a) A client who is ambulatoryb) a client scheduled for physical therapy at 1PMc) a client with a fever who is diaphoretic and restlessd) a postoperative client who has just received pain and medication

35. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

a) a client scheduled for a chest x-rayb) a client requiring daily dressing changesc) a postoperative client preparing for discharged) a client receiving oxygen via nasal cannula who had difficulty breathing during the previous shift


31) D- In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, acute neurological deficits, and those who have sustained chemical splashes to the eyes are classified as emergent and are the number 1 priority. Clients with conditions such as a simple

fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are the number 3 priority.

32) C- The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires urine specimen collections. The nursing assistant is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration.

33) D- When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

34) CThe RN would plan to care for the client who has a fever and is diaphoretic and restless first because this client’s needsare the priority. Waiting for pain medication to take effect before providing care to the postoperative client is best. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care.

35) D- Airway is always a highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options A, B, and C have needs that would be identified as intermediate priorities.

1. The nurse is providing instructions to a nursing assistant regarding care of an older client

29 | P a g e

with hearing loss. The nurse tells the assistant that clients with a hearing loss:a) are often distractedb) have middle ear changesc) respond to low-pitched tonesd) develop moist cerumen production

2. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which of the following would the nurse expect to observe?

a) a pink-colored tympanic membraneb) a pearly colored tympanic membranec) a transparent and clear tympanic membraned) a red, dull, thick and immobile tympanic membrane

3. The client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder involving this part of the ear?

a) pruritusb) tinnitusc) hearing lossd) burning in the ear

4. The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?

a) whisper a statement while the client blocks both earsb) whisper a statement with the examiner's back facing the clientc) whisper a statement and ask the client to repeat it while blocking one eard) stand 4 feet away from the client to ensure that the client can hear at this distance

5. During a hearing assessment, the nurse notes that the sound lateralizes to the client's left ear with the Weber test. The nurse analyzes these results as:

a) a normal findingb) the presence of nystagmusc) a sensorineural or conductive lossd) a conductive loss in the right ear


1) C- Presbycusis refers to the age-related irreversible degenerative changes of the inner ear that lead to decreased hearing ability. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched voice tones are heard more easily and can be interpreted by the older client. Options A, B, and D are not accurate.

2) D- Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

3) B- Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span. Options A, C, and D are not associated specifically with disorders of the inner ear.

4) C- In the voice test, the examiner stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.

5) C- In the Weber tuning fork test, the nurse places the vibrating tuning fork in the middle of the client’s head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear.

NCLEX Review about Ear Infection

30 | P a g e

6. The nurse is caring for a hearing-impaired client. Which of the following approaches will facilitate communication?

a) speak loudlyb) speak frequentlyc) speak at a normal volumed) speak directly into the impaired ear

7. A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially?

a) irrigation of the earb) instillation of diluted alcoholc) instillation of antibiotic ear dropsd) instillation of corticosteroid ointment

8. The nurse notes that the physician has documented a diagnosis of presbycusis on the client's chart. The nurse plans care knowing that the condition is:

a) tinnitus that occurs with agingb) nystagmus that occurs with agingc) a conductive hearing loss that occurs with agingd) a sensorineural hearing loss that occurs with aging

9. The nurse has conducted discharge teaching for a client who has had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective?

a) it is okay to take a shower and wash my hairb) I can resume my tennis lessons starting next weekc) I will take stool softeners as prescribed by my doctord) I should drink liquids through a straw fo the next 2 to 3 weeks

10. A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

a) increase sodium in the diet

b) avoid sudden head movementsc) lie still and watch the televisiond) increase fluid intake to 3L a day

NCLEX Review about Ear Infection:ANSWERS AND RATIONALE

6) C- Speaking in a normal tone to the client with impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

7) B- Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which then is removed using ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration and the impaction becomes worse.

8) D- Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options A, B, and C are incorrect.

9) C- Following ear surgery, the client needs to avoid straining when having a bowel movement. The client needs to be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. The client needs to avoid getting his or her head wet, washing hair, showering for 1 week, and rapidly moving the head, bouncing, and bending over for 3 weeks.

10) B

- The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.

31 | P a g e

Lying still and watching television will not control vertigo.

NCLEX Review about Ear Infection (11-15)NCLEX Review about Ear Infection

11.The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which of the following cranial nerves would identify a complication specifically associated with this surgery?

a) cranial nerve I, olfactoryb) cranial nerve IV, trochlearc) cranial nerve III, oculomotord) cranial nerve VII, facial nerve

12. The nurse assesses the client with a blunt injury sustained from a motor vehicle accident. Which assessment sign would indicate a basal skull fracture as a result of the injury?

a) epistaxisb) periorbital edemac) purulent drainage from the auditory canald) bloody or clear drainage from the auditory canal

13. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse determine could be the cause of the client's complaint?

a) doxycycline (Vibramycin)b) acetazolamide (Diamox)c) acetylsalicylic acid (aspirin)d) diltiazem hydrochloride (Cardizem)

14. The nurse prepares the client for an ear irrigation as prescribed by the physician. In performing the procedure, the nurse:

a) warms the irrigating solution to 98Fb) position the client with the affected side up following the irrigationc) directs a slow steady stream of irrigation solution toward the eardrumd) assists the client to turn his or her head so that the ear to be irrigated is facing upward

15. Ear drops are prescribed for an infant with otitis media. The most appropriate method to administer the ear drops to the infant is to:

a) pull up and back on the pinna and direct the solution onto the eardrumb) pull down and back on the pinna and direct the solution onto the eardrumc) pull down and back on the pinna and direct he solution toward the wall of the canald) pull up and back on the ear lobe and direct the solution toward the wall of the canal


11) D- Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

12) D- Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. This warrants immediate attention. Options A, B, and C are not specific to a basal skull fracture.

13) C- Aspirin is contraindicated for gastrointestinal bleed and is potentially ototoxic. The client should be advised to notify the prescribing physician so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options A, B, and D do not have side effects that are potentially associated with hearing difficulties.

14) A- Irrigation solutions that are not close to the client’s body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the ear wax and solution. Following the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

15) C- In a child younger than 3 years, the pinna is pulled down and straight back. The infant should be turned on the side with the affected ear uppermost. With the nondominant hand, the pinna is pulled down and back. The medication is administered by aiming it at

32 | P a g e

the wall of the canal rather than directly onto the eardrum. The infant should remain with the affected ear uppermost for 10 to 15 minutes to retain the solution. In the adult or a child older than 3 years, the pinna is pulled up and back to straighten the auditory canal.


16. The nurse is preparing to perform an otoscopic examination on an adult client. The nurse does which of the following to perform this examination?

a) pulls the pinna up and back before inserting the speculumb) pulls the earlobe down and back before inserting the speculumc) uses the smallest speculum available to decrease the discomfort of the examd) tilts the clients head forward and down before inserting the speculum

17. A nurse is providing diet instructions to a client with Meniere's disease who is being discharged from the hospital after admission for an acute attack. Which statement if made by the client indicates an understanding of the dietary measures to take to prevent further attacks?

a) I need to drink at least 3 liters of fluid per dayb) I need to restrict my carbohydrates intakec) I need to maintain a low-fat and low-cholesterol dietd) I need to be sure to consume foods that are low in sodium

18. A nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which of the following statements would be appropriate for the nurse to include?

a) the ear mold for the hearing aid should be washed with mild soap and water once a monthb) the hearing aid should be removed from the ear at the end of the day then turned off after removalc) the hearing aid contains a lifelong battery so you will not need to be concerned about changing batteriesd) the hearing aid should not be worn if an ear infection is present

19. A nurse is caring for a client with acute otitis media. In order to reduce pressure and allow fluid to drain, the nurse anticipates that which of the following would most likely be recommended to the client?

a) the administration of diphenhydramine (Benadryl)

capsulesb) a myringotomyc) strict bedrestd) a mastoidectomy

20. A nurse is developing a plan of care for a client with a diagnosis of Meniere's disease who is being admitted to the hospital. The priority nursing intervention in the plan of care should focus on:

a) safety measuresb) self-care measuresc) knowledge about medication therapyd) food items to avoid


16) A- The nurse tilts the client’s head slightly away and holds the otoscope upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. Options B, C, and D are incorrect.

17) D- Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière’s disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière’s disease.

18) D- The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use and the client should keep extra batteries on hand at all times. The client should wash the ear mold frequently with mild soap and water, with the use of a pipe cleaner to clean the cannula of the hearing aid.

19) B- A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear. Benadryl is an antihistamine with antiemetic properties. Strict bedrest is not necessary, although activity may be restricted. Additionally, bedrest would not assist in reducing pressure or allowing fluid to drain. In some cases, the mastoid bone is removed or partially removed for chronic otitis media.

33 | P a g e

20) A- Ménière’s disease can cause severe vertigo in the client. The priority in the nursing care plan should focus on safety issues to prevent falls or injury in the client. Although self-care measures, medication therapy, and dietary therapy may be components of the plan of care, safety is the priority issue.


21. A nurse is assigned to care for a client after a mastoidectomy. Which nursing intervention would be appropriate in the care of this client?

a) maintain a supine positionb) position the client on the affected side to promote drainagec) change the ear dressing dailyd) monitor for signs of facial nerve injury

22. A nurse is performing an assessment on a client with a diagnosis of Meniere's disease. The nurse anticipates that the client is most likely to report which of the following symptoms during an acute attack?

a) tinnitusb) headachec) fatigueinsomnia

23. A nurse has admitted a client with a diagnosis of an acute attack of Meniere's disease to the hospital. The nurse reviews the physician's orders for the client. Which order should the nurse question?

a) diphenhydramine (Benadryl)b) diazepam (Valium)c) atropine sulfated) ambulation 4 times daily

24. A nurse in the health care clinic is preparing to perform an otoscopic examination on adult client. In performing the examination, the nurse should:

a) position the client lying flat on the side of the ear be examinedb) pull the ear lobe down and back before inserting the speculumc) tilt the client's head forward before inserting the speculumd) pull the pinna up and back before inserting the speculum

25. A nurse is providing discharge instructions to the client being discharged after a fenestration procedure

for the treatment of otosclerosis. Which statement if made by the client indicates a need for further instruction?

a) I should take stool softeners to avoid straining when having a bowel movementb) I need to avoid washing my hair and showering for at least 1 weekc) I should avoid movements requiring bending over for at least 3 weeksd) I should use a straw to drink liquids for the next 2 to 3 weeks

NCLEX Review about Ear Infection: ANSWERS AND RATIONALE

21) D- After mastoidectomy, the nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse also should assess for signs of facial nerve injury (cranial nerve VII). The nurse also should monitor for signs of pain, dizziness, or nausea. The head of the bed should be elevated at least 30 degrees, and the client should be instructed to lie on the unaffected side. The client probably will have sutures, an outer ear packing, and a bulky dressing, which is removed on approximately the sixth day postoperatively.

22) A- Ménière’s disease results in a disturbance of the fluid of the endolymphatic system. The cause of the disturbance is not known. Attacks may be preceded by feelings of fullness in the ear or by tinnitus. Headaches, fatigue, and insomnia are not associated with this disorder.

23) D- Medical interventions during the acute phase of Ménière’s disease include using atropine sulfate or diazepam to decrease the autonomic nervous system function. Diphenhydramine may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bedrest during the acute attack. When allowed out of bed, the client will need assistance with walking, sitting, or standing.

24) D- The correct procedure for performing an otoscopic examination on an adult is to pull the pinna up and back to allow visualization of the external canal while slowly inserting the speculum. The nurse would tilt the client’s head slightly away and hold the otoscope upside down as if it were a large pen. The examination would be performed with the client in a sitting position. If the client were lying on the side to

34 | P a g e

be examined, examination of the affected ear would not be possible.

25) D- After ear surgery, clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, to avoid air travel, and to avoid coughing excessively. The client also should be instructed to avoid straining when having a bowel movement and should be instructed to take stool softeners as prescribed. The client should avoid getting the head wet, washing the hair, or showering for at least 1 week, and to avoid rapidly moving the head, bouncing, and bending over for at least 3 weeks.


26. The clinic nurse is preparing to provide care for a client who will need an ear irrigation to remove impacted cerumen. Which of the following will the nurse avoid when performing the irrigation?

a) position the client to turn the head so that the ear be irrigated is facing upwardb) warm the irrigating solution to a temperature that is close to body temperaturec) direct a slow steady stream of irrigation solution toward the upper wall of the ear canald) position the client with the affected side down after irrigation

27. A nursing student is performing an otoscopic examination in an adult client. The nursing instructor observes the student perform this procedure. Which observation by the instructor indicates that the student is using correct technique for the procedure?

a) pulling the pinna down and back before inserting the speculumb) pulling the earlobe down and back before inserting the speculumc) using the smallest speculum available d) tilting the client's head slightly away and holding the otoscope upside before inserting the speculum

28. A nurse is preparing to perform a Weber test on a client. The nurse obtains which item needed to perform this test?

a) a tongue bladeb) a stethoscope

c) a tuning forkd) a reflex hammer

29. The home care nurse is visiting a client who was recently diagnosed with a hearing impairment. The nurse prepares to instruct the client's spouse in which measure that will facilitate communication?

a) speak frequently to the client to provide sensory stimulationb) speak loudly to the client to facilitate hearingc) speak in a normal tone and face the client when speakingd) speak directly into the impaired ear to facilitate hearing

30. A nurse is providing discharge instructions to a client who had a fenestration procedure for the treatment of otosclerosis. The nurse instructs the client to:

a) drink liquids through a straw for the next 2 to 3 weeksb) shower daily to prevent infectionc) avoid air traveld) resume all normal activities in 1 week


26) A- During the irrigation, the client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the earwax and solution. Delivery of irrigation solutions at temperatures that are notclose to body temperature can cause discomfort for the client and may result in tissue injury, nausea, and vertigo. A slow, steady stream of solution should be directed toward the upper wall of the ear canal, not toward the tympanic membrane. After the irrigation, the client should lie on the affected side for a period of time that is necessary to allow the irrigating solution to finish draining (usually 10 to 15 minutes). Too much force could cause the tympanic membrane to rupture.

27) D- In the otoscopic examination, the nurse tilts the client’s head slightly away and holds the otoscope

35 | P a g e

upside down as if it were a large pen. The pinna is pulled up and back and the nurse visualizes the external canal while slowly inserting the speculum. A small speculum is used in pediatric clients. The nurse may not be able to adequately visualize the ear canal if a small speculum is used in the adult client.

28) C- A tuning fork is needed to perform the Weber test, during which the nurse places the vibrating tuning fork at the midline of the client’s forehead or above the upper lip over the teeth. Normally, the sound is heard equally in both earsby bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear. The items identified in options A, B, and D are not needed to perform the Weber test.

29) C- Measures that facilitate hearing in the client with a hearing impairment problem include speaking in a normal tone; avoiding shouting; talking directly to the client while facing the client; and speaking clearly. If the client does not seem to understand what is said, the statement should be expressed differently. Moving closer to the client and toward the better ear may facilitate communication, but talking directly into the impaired ear should be avoided.

30) CAfter ear surgery, the client needs to be instructed to avoid air travel, avoid drinking through a straw for 2 to 3 weeks, and to avoid coughing excessively. In addition, the client should avoid straining when having a bowel movement, as well as washing the hair, getting the head wet, or showering for 1 week. The client also needs to avoid rapidly moving the head, bouncing, and bending over for 3 weeks.


31. A clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse performs this test for the purpose of determining:

a) the client's ability to ambulateb) the functional status of the vestibular apparatus in the inner earc) the intactness of the retinal structure of the eye

d) the intactness of the tympanic membrane

32. A clinic nurse is performing an otoscopic examination on an adolescent who was hit in the ear with a basketball during a neighborhood game. A perforated eardrum is suspected. Which of the following would the nurse expect to observe if the eardrum is perforated?

a) a colony of black dots on the eardrumb) dense white patches on the eardrumc) a red bulging eardrumd) a round or oval darkened area on the eardrum

33. A caloric test is ordered for a client suspected of having disease of the labyrinth. The nurse would obtain which of the following essential items in preparation for this test?

a) an otoscopeb) an opthalmoscopec) a tongue bladed) an emesis basin

34. A nurse educator is conducting an in-service education session to the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which of the following clients?

a) a client who became deaf before learning to speakb) a client with bilateral profound hearing lossc) a client who communicates primarily by speechd) a client who received no benefit from conventional hearing aids

35. A nurse is observing a nursing assistant communicating with a client who is deaf. The nurse will intervene if which of the following behaviors is observed?

a) the nursing assistant is speaking directly to the clientb) the nursing assistant touches the client's arm to gain his or her attentionc) the nursing assistant faces the client when speaking to the clientd) the nursing assistant overenunciates words when speaking

36 | P a g e


31) B- The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception. Options A, C, and D are incorrect.

32) DA round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red and bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection.

33) A- A caloric test is contraindicated in a client with a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine if the ear canal contains cerumen, which must be removed before the test. An ophthalmoscope, a tongue blade, and an emesis basin are not essential items.

34) A- Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure.

35) D- Overenunciating words does not make lip reading easier and is demeaning to the deaf person. It is best to speak in a normal manner. Options A, B, and C are appropriate communication strategies for the client who is deaf.


36. A nurse is planning a presentation on noise prevention and ear protection for a display booth at a local health fair. The nurse plans to incorporate which important concept regarding hearing loss in the presentation?

a) siting near loud music is not harmfulb) ear plugs or other protectors are necessary only when use of power toolsc) prolonged ringing in the ears after loud noises is normald) cup the hands over the ears if loud noise is expected suddenly

37. A nurse instructs a client in the use of a hearing aid. The nurse includes which of the following in the instructions?

a) check the battery to ensure that it is working before useb) leave the hearing aid in place while showeringc) hearing aids do not require any cared) a water-soluble lubricant is used on the hearing aid before insertion

38. A nurse has given a client at risk for motion sickness suggestions about medications that can prevent an occurrence. The nurse determines that the client has correctly learned the information if the client states to takemedication at what time before the triggering event?

a) at least 1/2 day beforeb) at least 1 hour beforec) at least the day befored) at least 2 days before

39. An adult client makes an appointment with an ear specialist because of the frequent recurrence of middle earinfections. In performing an intake assessment of the client, the nurse would ask about which of the following as a risk factor related to infection of the ears?

a) exposure to loud noiseb) use of drilling and other power toolsc) congenital abnormalitiesd) occupational noise

40. A nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Teaching for this client will include which of the following statements?

a) drive only when feelings of dizziness have not been experienced for several hours

37 | P a g e

b) go to the bedroom and lie down when vertigo is experiencedc) remove throw rugs and clutter in the homed) turn the head slowly when spoken to

NCLEX REVIEW ABOUT EAR INFECTION:ANSWERS AND RATIONALE

36) D- A variety of ear protective devices are available commercially. These include disposable and reusable plugs, headbands, and foam-filled muffs. They should be used around any type of loud noise, such as from power tools, machinery, lawn mowers, chain saws, or other equipment. Sitting near loud music should be avoided wheneverpossible. If a loud noise is suddenly anticipated, the ears should be covered for protection. The client should see a physician for tinnitus or hearing loss after exposure to a loud noise.

37) A- The battery of the hearing aid should be checked before use. The hearing aid should be removed for showering, because it should not get wet. It also should be put away in its case at night. It should be cleaned according to manufacturer’s directions, which usually consist of washing with warm soapy water, followed by thorough drying. Lubricants or other solvents are not used on the hearing aid.

38) B- To be maximally effective, medications to prevent motion sickness should be taken at least 1 hour before the triggering event. Medications that are commonly used for this purpose include dimenhydrinate (Dramamine), scopolamine (Transderm-Scop), promethazine (Phenergan), and prochlorperazine (Compazine). Options A, C, and D are incorrect.

39) C- Otitis media (middle ear infection) is associated with colds, allergies, sore throats, and blockage of the eustachian tube. Risk factors include a young age (usually a childhood disease), congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history of otitis media, recent upper respiratory infections, and allergies. Options A, B, and D can cause hearing loss. Hearing loss can occur as a result of an acute loud noise (acoustic trauma) or by the chronic exposure to loud noise (noise-induced hearing loss).

40) C

- The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should maintain the home without throw rugs and in a state that is free of clutter, because the effort of trying to regain balance after slipping could trigger the onset of vertigo.

http://www.nclexpinoy.com/2010/10/online-nursing-practice-test-about-ear_12.html

38 | P a g e



Nclex for Rn

Documents

Transcript of Nclex for Rn