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NCLEX-RN Exam Questions - Part 146
1. The nurse is teaching a client how to perform monthly testicular self-examination (TSE) and states that it is best to perform the procedure right after showering.This statement is made by the nurse based on the knowledge that:
A) The client is more likely to remember to perform the TSE when in the nude
B) When the scrotum is exposed to cool temperatures, the testicles become large and bulky
C) The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate
D) The examination will be less painful at this time
2. The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
A) Pedal pulses 11 (weak)
B) Twenty-four-hour intake 1000 mL/day for past 2 days
C) Serum potassium 3.3
D) Pulse rate 150 bpm
3. A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurses first action when admitting the client will be to:
A) Obtain vital signs
B) Connect the client to the cardiac monitor
C) Ask the client if he is still having chest pain
D) Complete the history profile
4. The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the clients chief complaint?
A) 'I - ve been having a dull pain at the upper left shoulder.'
B) 'My legs have been numb for three months.'
C) 'I - ve only been urinating three times a day lately.'
D) 'I don - t remember anything in particular, I just haven - t felt well.'
5. The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
A) Will bind calcium and therefore interfere with its metabolism
B) Will cause more premenstrual cramping
C) Interferes with iron absorption because the iron precipitates as an insoluble substance
D) Causes competition at iron-receptor sites between iron and vitamin B1
A) The client is more likely to remember to perform the TSE when in the nude
B) When the scrotum is exposed to cool temperatures, the testicles become large and bulky
C) The scrotum will be softer and more relaxed after a warm shower, making the testicles easier to palpate
D) The examination will be less painful at this time
2. The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
A) Pedal pulses 11 (weak)
B) Twenty-four-hour intake 1000 mL/day for past 2 days
C) Serum potassium 3.3
D) Pulse rate 150 bpm
3. A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurses first action when admitting the client will be to:
A) Obtain vital signs
B) Connect the client to the cardiac monitor
C) Ask the client if he is still having chest pain
D) Complete the history profile
4. The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the clients chief complaint?
A) 'I - ve been having a dull pain at the upper left shoulder.'
B) 'My legs have been numb for three months.'
C) 'I - ve only been urinating three times a day lately.'
D) 'I don - t remember anything in particular, I just haven - t felt well.'
5. The nurse is collecting a nutritional history on a 28- year-old female client with iron-deficiency anemia and learns that the client likes to eat white chalk. When implementing a teaching plan, the nurse should explain that this practice:
A) Will bind calcium and therefore interfere with its metabolism
B) Will cause more premenstrual cramping
C) Interferes with iron absorption because the iron precipitates as an insoluble substance
D) Causes competition at iron-receptor sites between iron and vitamin B1
1. Right Answer: C
Explanation: (A) Nudity is not a trigger for reminding males to perform TSE. (B) Testicles become more firm when exposed to cool temperatures, but not large and bulky. (C)The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. (D) The examination should not be painful.
2. Right Answer: B
Explanation: (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
3. Right Answer: B
Explanation: (A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the clients rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions.
4. Right Answer: D
Explanation: (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
5. Right Answer: C
Explanation: (A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients.
Explanation: (A) Nudity is not a trigger for reminding males to perform TSE. (B) Testicles become more firm when exposed to cool temperatures, but not large and bulky. (C)The testicles will be lower and more easily palpated with warmer temperatures. A protective mechanism of the body to protect sperm production is for the scrotum to pull closer to the body when exposed to cooler temperatures. (D) The examination should not be painful.
2. Right Answer: B
Explanation: (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
3. Right Answer: B
Explanation: (A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the clients rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions.
4. Right Answer: D
Explanation: (A, B, C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. (D) Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.
5. Right Answer: C
Explanation: (A) Eating chalk is not related to calcium and its absorption. (B) Poor nutritional habits may result in increased discomfort during premenstrual days, but this is not a primary reason for the client to stop eating chalk. Premenstrual discomfort has not been mentioned. (C) Iron is rendered insoluble and is excreted through the gastrointestinal tract. (D) There is no competition between the two nutrients.
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