NCLEX RN model questions 2

^{1. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah’s Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for nurse Christian who’s caring for the client to:}

^{a. realize the surgeon has the right to refuse to care for the client
b. advise the surgeon to arrange for an alternate cardiac surgeon
c. tell the client that she can donate her own blood for the procedure
d inform the client that her decision could shorten her life}

 ^{2. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:}

^{a. unhappiness about the change in leadership
b. unexpressed feelings and emotions among the staff
c.fatigue from overwork and understaffing
d. failure to incorporate staff in decision making}

^{3.  Nurse Chrisopher is caring for an infant with congenital clubfoot. After the final cast has been removed, which member of the health care team will most likely help the infant with leg and ankle exercises and provide his parents with a home exercise regimen?}

^{a.Occupational therapist
b. Physical therapist
c. Recreational therapist
d. Speech therapist}

^{4. Which statement reflects appropriate documentation in the medical record of a hospitalized client?}

^{a.    Small pressure ulcer noted on left leg
b.    Client seems to be mad at the physician
c.    Client had a good day
d.    Client’s skin is moist and cool}

^{5. Critical pathways of care refer to:}

^{a.    a plan of care that provides outcome-based guidelines with a designated length of stay
b.    a plan of care designed for physicians to prescribe medications
c.    a design of treatment that includes approved therapies
d.    a technique in therapy to care for the client holistically}

^{Urinary/ Renal Function/ Electrolyte Imbalance}

<sup>6. A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate?

a. “Make sure to eat enough fiber to prevent constipation.”
b. “Try drinking coffee throughout the day.”
c. “Use scented powders to disguise any odor.”
d. “Limit the number of times you urinate during the day.”</sup>

^{7. A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?}

^{a. Restricting fluid intake to reduce the need to void
b. Establishing a predetermined fluid intake pattern for the client
c. Encouraging the client to increase the time between voidings
d. Assessing present voiding patterns}

^{8. A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client’s risk of:}

^{a. a decreased serum phosphate level secondary to kidney failure.
b. an increased serum calcium level secondary to kidney failure.
c. water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
d. metabolic alkalosis secondary to retention of hydrogen ions.}

^{9. Which is the correct term for the ability of the kidneys to clear solutes from the plasma?}

^{a. Glomerular filtration rate (GFR)
b. Renal clearance
c. Specific gravity
d. Tubular secretion}

^{10. A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?}

^{a. Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose.
b. Administer furosemide (Lasix) 20 mg I.V.
c. Encourage oral fluids.
d. Start hemodialysis after a temporary access is obtained.}

^{11. Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?}

^{a. Increased red blood cell count
b. Decreased serum potassium level
c. Increased serum calcium level
d. Increased serum creatinine level} 

^{12. A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?}

^{a. Serum sodium level of 135 mEq/L
b. Serum potassium level of 4.9 mEq/L
c. Temperature of 99.2° F (37.3° C)
d. Urine output of 20 ml/hour}

^{13. A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?}

^{a. Urinary retention
b. Painless hematuria
c. Fever
d. Frequency}

^{14. After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?}

^{a. “The effluent should be allowed to drain by gravity.”
b. “It is important to use strict aseptic technique.”
c. “The infusion clamp should be open during infusion.”
d. “It is appropriate to warm the dialysate in a microwave.”}

^{15. Which of the following is a characteristic of a normal stoma?}

^{a. Painful
b. No bleeding when cleansing stoma
c. Dry in appearance
d. Pink color} 

^{16. To assess circulating oxygen levels, the 2001 Kidney Disease Outcomes Quality Initiative: Management of Anemia Guidelines recommends the use of which of the following diagnostic tests?}

^{a. Hemoglobin
b. Hematocrit
c. Arterial blood gases
d. Serum iron levels}

^{17. A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?}

^{a. History of hyperparathyroidism
b. History of osteoporosis
c. Recent history of streptococcal infection
d. Previous episode of acute pyelonephritis}

^{18. Which type of incontinency refers to the involuntary loss of urine due to medications?}

^{a. Overflow
b. Urge
c. Reflex
d. Iatrogenic}

^{19. The nurse is to check residual urine amounts for a client experiencing urinary retention. Which of the following would be most important?}

^{a. Catheterize the client immediately after the client voids.
b. Check for residual after the client reports the urge to void.
c. Set up a routine schedule of every 4 hours to check for residual urine.
d. Record the volume of urine obtained.}

^{20. The client asks the nurse about the functions of the kidney. Which should the nurse include when responding to the client? Select all that apply.}

^{a. Vitamin D synthesis
b. Secretion of prostaglandins
c. Vitamin B production
d. Secretion of insulin
e. Regulation of blood pressure}

^{21. A client is scheduled for a creatinine clearance test. The nurse should explain that this test is done to assess the kidneys’ ability to remove a substance from the plasma in:}

^{a. 1 hour.
b. 24 hours.
c. 1 minute.
d. 30 minutes.}

^{22. A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?}

^{a. Impaired urinary elimination
b. Toileting self-care deficit
c. Risk for infection
d. Activity intolerance}

^{23. When preparing a client for hemodialysis, which of the following would be most important for the nurse to do?}

^{a. Check for thrill or bruit over the access site.
b. Warm the solution to body temperature.
c. Inspect the catheter insertion site for infection.
d. Add the prescribed drug to the dialysate.}

^{24. A physician orders cystoscopy and random biopsies of the bladder for a client who reports painless hematuria. Test results reveal carcinoma in situ in several bladder regions. To treat bladder cancer, the client will have a series of intravesical instillations of bacillus Calmette-Guérin (BCG), administered 1 week apart. When teaching the client about BCG, the nurse should mention that this drug commonly causes:}

^{a. delayed ejaculation.
b. hematuria.
c. impotence.
d. renal calculi.}

^{25. A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?}

^{a. “Be aware that your urine will be cherry-red for 5 to 7 days.”
b. “Increase your fluid intake to 2 to 3 L per day.”
c. “Apply an antibacterial dressing to the incision daily.”
d. “Take your temperature every 4 hours.”}

^ANSWERS.

1. Answer: A
Rationale: Physicians have an ethical and legal right to refuse to care for any client in a non-emergency situation when standard medical care isn’t acceptable to the client. It isn’t the responsibility of the surgeon to find an alternate. Jehovah’s Witnesses don’t believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client’s right of autonomy.
2. Answer: B
Rationale: The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation where the nurses have unexpressed feelings and emotions. Although the other answers could be contributing to the problematic situation, they’re less likely to be the cause. 
 3. Answer: B
Rationale: After the final cast has been removed, foot and ankle exercises may be necessary to improve range of motion. A physical therapist should work with the child. A physical therapist is trained to help clients restore function and mobility, which will prevent further disability.

4. Answer: D
Rationale: Documentation should include data that the nurse obtains using only observations that are heard, seen, smelled, or felt. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client’s feelings is not. Stating that the client had a good day doesn’t provide precise enough information to be useful.

5. Answer: A
Rationale: Critical pathways are defined as a provision of care in a case management system. The pathways provide outcome-based guidelines for goal achievement within a designated length of stay. Critical pathways are to be used by the treatment team, not just by the physician. Pathways are designated lengths of stay, not therapies.

6. Answer: A

Rationale: Suggestions to manage urinary incontinence include avoiding constipation such as eating adequate fiber and drinking adequate amounts of fluid. Scented powders, lotions, or sprays should be avoided because they can intensify the urine odor, irritate the skin, or cause a skin infection. Stimulants such as caffeine, alcohol, and aspartame should be avoided. The client should void regularly, approximately every 2 to 3 hours to ensure bladder emptying.

7. Answer: D

Rationale: The guidelines for initiating bladder retraining include assessing the client’s present intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client’s fluid intake won’t reduce or prevent incontinence. The client should be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

8. Answer: C
Rationale: The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys’ inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

9. Answer: B
Rationale: Renal clearance refers to the ability of the kidneys to clear solutes from the plasma. GFR is the volume of plasma filtered at the glomerulus into the kidney tubules each minute. Specific gravity reflects the weight of particles dissolved in the urine. Tubular secretion is the movement of a substance from the kidney tubule into the blood in the peritubular capillaries or vasa recta.
10. Answer: A
Rationale: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn’t be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn’t fluid-overloaded so his urine output won’t increase with furosemide, which would actually worsen the client’s condition. The client doesn’t require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.

11. Answer: D
 Rationale: In renal failure, laboratory blood tests reveal elevations in BUN, creatinine, potassium, magnesium, and phosphorus. Calcium levels are low. The RBC count, hematocrit, and hemoglobin are decreased.

12.  Answer: D
Rationale: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client’s urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings. 
13. Answer: B
Rationale: The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency. Later symptoms are related to metastases and include pelvic pain, urinary retention (if the tumor blocks the bladder outlet), and urinary frequency from the tumor occupying bladder space.

14. Answer: D
 Rationale: The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.
15. Answer: D
 Rationale: Characteristics of a normal stoma include a pink and moist appearance. It is insensitive to pain because it has no nerve endings. The area is vascular and may bleed when cleaned.

16. Answer: A
 Rationale: Although hematocrit has always been the blood test of choice to assess for anemia, the 2001 Kidney Disease Outcomes Quality Initiative: Management of Anemia Guidelines, recommend that anemia be quantified using hemoglobin rather than hematocrit measurements. Hemoglobin is recommended as it is more accurate in the assessment of circulating oxygen than hematocrit. Serum iron levels measure iron storage in the body. Arterial blood gases assess the adequacy of oxygenation, ventilation, and acid-base status.
17. Answer: C
 Rationale: Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client’s risk for chronic pyelonephritis.

18. Answer: D
Rationale: Iatrogenic incontinence is the involuntary loss of urine due to medications. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.

19. Answer: A
Rationale: To obtain accurate residual volumes, it is important that clients void first and that catheterization occur immediately after the attempt. The nurse should record both the volume voided (even if it is zero) and the volume obtained by catheterization. Intermittent catheterizations are performed based on a schedule, usually 3 to 4 times per day. Residual urine refers to the amount remaining in the bladder after voiding. It is essential that the client voids.

20. Answers: A, B, E
 Rationale: Functions of the kidney include secretion of prostaglandins, regulation of blood pressure, and synthesis of aldosterone and vitamin D. The pancreas secretes insulin. The body does not produce Vitamin B.

21. Answer: C
 Rationale: The creatinine clearance test determines the kidneys’ ability to remove a substance from the plasma in 1 minute. It doesn’t measure the kidneys’ ability to remove a substance over a longer period.

22. Answer: C
 Rationale: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.

23. Answer: A
 Rationale: When preparing a client for hemodialysis, the nurse would need to check for a thrill or bruit over the vascular access site to ensure patency. Inspecting the catheter insertion site for infection, adding the prescribed drug to the dialysate, and warming the solution to body temperature would be necessary when preparing a client for peritoneal dialysis.

24. Answer: B
 Rationale: Intravesical instillation of BCG commonly causes hematuria. Other common adverse effects of BCG include urinary frequency and dysuria. Less commonly, BCG causes cystitis, urinary urgency, urinary incontinence, urinary tract infection, abdominal cramps or pain, decreased bladder capacity, tissue in urine, local infection, renal toxicity, and genital pain. BCG isn’t associated with renal calculi, delayed ejaculation, or impotence.
25. Answer: B
Rationale: The nurse should instruct the client to increase his fluid intake. Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary system. Measuring temperature every 4 hours isn’t needed. Lithotripsy doesn’t require an incision. Hematuria may occur for a few hours after lithotripsy but should then disappear.