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NCLEX-RN Exam Questions - Part 116
1. A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?
A) Offer her oral hygiene before and after meals.
B) Encourage her to consume milk products.
C) Encourage her to engage in an activity before a meal to stimulate her appetite.
D) Restrict her fluid intake to three glasses of water a day.
2. A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
A) 'Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.'
B) 'It - s OK for you to donate because the blood bank has a test that is 100% effective.'
C) 'You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.'
D) 'It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.'
3. A 50-year-old male client is to receive chemotherapy. The physicians orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:
A) Give antiemetics when nausea is experienced and continue on a regular schedule for 12 - 24 hours.
B) Give antiemetics prior to the client receiving chemotherapy and continue on a regular basis for at least24 - 48 hours after chemotherapy.
C) Give antiemetics one at a time because combinations of antiemetics cause overwhelming side effects.
D) Give antiemetics intermittently during the entire course of chemotherapy.
4. A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
A) Respiratory rate of 16 breaths/min
B) Pulse rate of 80 bpm
C) Complaints of muscle aches
D) A sore throat
5. Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
A) She should be able to control evacuation of her bowels.
B) She should be able to return to a regular diet.
C) She should be able to resume sexual activity.
D) She should be able to manage her own care.
A) Offer her oral hygiene before and after meals.
B) Encourage her to consume milk products.
C) Encourage her to engage in an activity before a meal to stimulate her appetite.
D) Restrict her fluid intake to three glasses of water a day.
2. A female client is concerned that she is in a 'high-risk' group for the development of acquired immunodeficiency syndrome (AIDS). She wants to know about the advisability of donating blood. Which of the following responses is correct?
A) 'Individuals who donate blood are at risk of getting the AIDS virus. You should not donate.'
B) 'It - s OK for you to donate because the blood bank has a test that is 100% effective.'
C) 'You should not donate since it takes time to develop antibodies to the AIDS virus. If you donate blood before you develop the antibody, you could pass it on in the blood.'
D) 'It is not a good idea for you to donate. If you have AIDS, the information is made public and could destroy your personal life.'
3. A 50-year-old male client is to receive chemotherapy. The physicians orders include antiemetics. When planning his care, the nurse should take into consideration that antiemetics are best administered in the following way:
A) Give antiemetics when nausea is experienced and continue on a regular schedule for 12 - 24 hours.
B) Give antiemetics prior to the client receiving chemotherapy and continue on a regular basis for at least24 - 48 hours after chemotherapy.
C) Give antiemetics one at a time because combinations of antiemetics cause overwhelming side effects.
D) Give antiemetics intermittently during the entire course of chemotherapy.
4. A 30-year-old female client is receiving antineoplastic chemotherapy. Which of the following symptoms should especially concern the nurse when caring for her?
A) Respiratory rate of 16 breaths/min
B) Pulse rate of 80 bpm
C) Complaints of muscle aches
D) A sore throat
5. Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?
A) She should be able to control evacuation of her bowels.
B) She should be able to return to a regular diet.
C) She should be able to resume sexual activity.
D) She should be able to manage her own care.
1. Right Answer: A
Explanation: (A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the clients appetite, increase her feelings of well-being, and remove the taste and odor of sputum. (B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client. (C) Exercise prior to a meal would require increased O2 consumption and most likely would decrease the clients ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions.
2. Right Answer: C
Explanation: (A) The AIDS virus cannot be transmitted to the donor through the blood donation procedure. (B) The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. (C) It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. (D) For reasons of confidentiality, information about individuals infected with AIDS is not made public.
3. Right Answer: B
Explanation: (A) Nausea is more difficult to control if antiemetics are withheld until nausea is experienced. (B) Antiemetics should be given prophylactically at the beginning of chemotherapy and continued on an around-the-clock basis to prevent nausea. (C) Combinations of antiemetics give the best control for nausea by blocking various causes of nausea induced by chemotherapy. (D) Antiemetics should be given around the clock during the course of chemotherapy. This prevents nausea from developing and prevents anticipatory nausea during subsequent chemotherapy administrations.
4. Right Answer: D
Explanation: (A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life- threatening situation.
5. Right Answer: A
Explanation: (A) Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. (B)The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. (C) The client should be able to resume sexual activity. She will be able to wear a pouch. (D) The client has no other health or mental problems and should be able to manage her own ileostomy.
Explanation: (A) Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the clients appetite, increase her feelings of well-being, and remove the taste and odor of sputum. (B) Milk causes thick sputum; therefore, milk products would not be beneficial for this client. (C) Exercise prior to a meal would require increased O2 consumption and most likely would decrease the clients ability to eat. (D) Clients with respiratory diseases need increased fluid to liquefy secretions.
2. Right Answer: C
Explanation: (A) The AIDS virus cannot be transmitted to the donor through the blood donation procedure. (B) The test for the AIDS virus is not absolutely foolproof; therefore, it is not wise for a person with known risk factors to donate blood. (C) It takes time for antibodies to the AIDS virus to develop. An infected individual could donate contaminated blood without it testing positive for the virus. (D) For reasons of confidentiality, information about individuals infected with AIDS is not made public.
3. Right Answer: B
Explanation: (A) Nausea is more difficult to control if antiemetics are withheld until nausea is experienced. (B) Antiemetics should be given prophylactically at the beginning of chemotherapy and continued on an around-the-clock basis to prevent nausea. (C) Combinations of antiemetics give the best control for nausea by blocking various causes of nausea induced by chemotherapy. (D) Antiemetics should be given around the clock during the course of chemotherapy. This prevents nausea from developing and prevents anticipatory nausea during subsequent chemotherapy administrations.
4. Right Answer: D
Explanation: (A) A respiratory rate of 16 breaths/min is normal and is not a cause for alarm. (B) A pulse rate of 80 bpm is normal and is not a cause for alarm. (C) Complaints of muscle aches are unrelated to her receiving chemotherapy. There may be other causes related to her hospital stay or the disease process. (D) A sore throat is an indication of a possible infection. A client receiving chemotherapy is at risk of neutropenia. An infection in the presence of neutropenia can result in a life- threatening situation.
5. Right Answer: A
Explanation: (A) Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. (B)The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. (C) The client should be able to resume sexual activity. She will be able to wear a pouch. (D) The client has no other health or mental problems and should be able to manage her own ileostomy.
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