NCLEX PRACTICE QUESTIONS PART 11
🛃 (Questions No. 101 - 150)
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📋Answers OF These Practice Questions are given at the End of Questions
101. What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
❍ A. Solid foods should not be given until the extrusion reflex disappears at 8–10 months of age.
❍ B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
❍ C. Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
❍ D. Solid foods should begin with fruits and vegetables.
102. When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find:
❍ A. No fetal movement
❍ B. Minimal fetal movement
❍ C. Moderate fetal movement
❍ D. Active fetal movement
103. A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
❍ A. “I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.”
❍ B. “I need to go back on a low-phenylalanine diet before I get pregnant.”
❍ C. “Fresh fruits and raw vegetables will make good betweenmeal snacks for me.”
❍ D. “My baby could be mentally retarded if I don’t stick to a diet eliminating phenylalanine.”
104. The nurse is teaching the mother of an infant with galactosemia. Which information should be included in the nurse’s teaching?
❍ A. Check food and drug labels for the presence of lactose.
❍ B. Foods containing galactose can be gradually added.
❍ C. Future children will not be affected.
❍ D. Sources of galactose are essential for growth.
105. Which finding is associated with Tay Sachs disease?
❍ A. Pallor of the conjunctiva
❍ B. Cherry-red spots on the macula
❍ C. Blue-tinged sclera
❍ D. White flecks in the iris
106. A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
❍ A. Withholding all morning medications
❍ B. Ordering a CBC and CPK
❍ C. Administering prescribed anti-Parkinsonian medication
❍ D. Transferring the client to a medical unit
107. A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
❍ A. Calcium-rich foods
❍ B. Canned or frozen vegetables
❍ C. Processed meat
❍ D. Raw fruits and vegetables
108. A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
❍ A. Abdominal pain and anorexia
❍ B. Fatigue and bruising
❍ C. Bleeding and pallor
❍ D. Petechiae and mucosal ulcers
109. A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
❍ A. Preventing infection
❍ B. Administering antipyretics
❍ C. Keeping the skin free of moisture
❍ D. Limiting oral fluid intake
110. A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
❍ A. Sublimaze (fentanyl)
❍ B. Pavulon (pancuronium bromide)
❍ C. Versed (midazolam)
❍ D. Atarax (hydroxyzine)
111. A client with a history of diverticulitis complains of abdominal pain, fever, and diarrhea. Which food is responsible for the client’s symptoms?
❍ A. Mashed potatoes
❍ B. Steamed carrots
❍ C. Baked fish
❍ D. Whole-grain cereal
112. The home health nurse is visiting a client with Paget’s disease. An important part of preventive care for the client with Paget’s disease is:
❍ A. Keeping the environment free of clutter
❍ B. Advising the client to see the dentist regularly
❍ C. Encouraging the client to take the influenza vaccine
❍ D. Telling the client to take a daily multivitamin
113. The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
❍ A. The tail of the pancreas
❍ B. The head of the pancreas
❍ C. The body of the pancreas
❍ D. The entire pancreas
114. A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
❍ A. Weight gain
❍ B. Hair loss
❍ C. Sore throat
❍ D. Brittle nails
115. Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:
❍ A. Uterine atony
❍ B. Retained placental fragments
❍ C. Cervical laceration
❍ D. Perineal tears
116. On a home visit, the nurse finds four young children alone. The youngest of the children has bruises on the face and back and circular burns on the inner aspect of the right forearm. The nurse should:
❍ A. Contact child welfare services
❍ B. Transport the child to the emergency room
❍ C. Take the children to an abuse shelter
❍ D. Stay with the children until an adult arrives
117. A client is diagnosed with post-traumatic stress disorder following a rape by an unknown assailant. The nurse should give priority to:
❍ A. Providing a supportive environment
❍ B. Controlling the client’s feelings of anger
❍ C. Discussing the details of the attack
❍ D. Administering a hypnotic for sleep
118. The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
❍ A. Preventing addiction
❍ B. Alleviating pain
❍ C. Facilitating mobility
❍ D. Preventing nausea
119. A client with emphysema is receiving intravenous aminophylline. Which aminophylline level is associated with signs of toxicity?
❍ A. 5 micrograms/mL
❍ B. 10 micrograms/mL
❍ C. 20 micrograms/mL
❍ D. 25 micrograms/mL
120. Which finding is the best indication that a client with ineffective airway clearance needs suctioning?
❍ A. Oxygen saturation
❍ B. Respiratory rate
❍ C. Breath sounds
❍ D. Arterial blood gases
121. A client with tuberculosis has a prescription for Myambutol (ethambutol HCl). The nurse should tell the client to notify the doctor immediately if he notices:
❍ A. Gastric distress
❍ B. Changes in hearing
❍ C. Red discoloration of body fluids
❍ D. Changes in color vision
122. The primary cause of anemia in a client with chronic renal failure is:
❍ A. Poor iron absorption
❍ B. Destruction of red blood cells
❍ C. Lack of intrinsic factor
❍ D. Insufficient erythropoietin
123. Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
❍ A. Providing the client with a favorite meal for dinner
❍ B. Asking if the client has allergies to shellfish
❍ C. Encouraging fluids the evening before the test
❍ D. Telling the client what to expect during the test
124. A client has ataxia following a cerebral vascular accident. The nurse should:
❍ A. Supervise the client’s ambulation
❍ B. Measure the client’s intake and output
❍ C. Request a consult for speech therapy
❍ D. Provide the client with a magic slate
125. The doctor has prescribed aspirin 325mg daily for a client with transient ischemic attacks. The nurse explains that aspirin was prescribed to:
❍ A. Prevent headaches
❍ B. Boost coagulation
❍ C. Prevent cerebral anoxia
❍ D. Decrease platelet aggregation
126. The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
❍ A. Mix the insulin with Dextrose 5% in Water
❍ B. Flush the IV tubing with the insulin solution and discard the first 50mL
❍ C. Avoid using a pump or controller with the infusion
❍ D. Mix the insulin with Ringer’s lactate
127. While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HB8 AG. The nurse recognizes that the client:
❍ A. Has chronic hepatitis B
❍ B. Has recovered from hepatitis B infection
❍ C. Has immunity to infection with hepatitis C
❍ D. Has no chance of spreading the infection to others
128. A client with tuberculosis who has been on combined therapy with rifampin and isoniazid asks the nurse how long he will have to take medication. The nurse should tell the client that:
129. Which developmental milestone puts the 4-month-old infant at greatest risk for injury?
❍ A. Switching objects from one hand to another
❍ B. Crawling
❍ C. Standing
❍ D. Rolling over
130. A newborn is diagnosed with congenital syphilis. Classic signs of congenital syphilis are:
❍ A. Red papular rash, desquamation, white strawberry tongue
❍ B. Rhinitis, maculopapular rash, hepatosplenomegaly
❍ C. Red edematous cheeks, maculopapular rash on the trunk and extremities
❍ D. Epicanthal folds, low-set ears, protruding tongue
131. Infants should be restrained in a car seat in a semi-reclined position facing the rear of the car until they weigh:
❍ A. 10 pounds
❍ B. 15 pounds
❍ C. 20 pounds
❍ D. 25 pounds
132. The nurse is caring for a client with irritable bowel syndrome. Irritable bowel syndrome is characterized by:
❍ A. Development of pouches in the wall of the intestine
❍ B. Alternating bouts of constipation and diarrhea
❍ C. Swelling, thickening, and abscess formation
❍ D. Hypocalcemia and iron-deficiency anemia
133. A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client’s discharge care plan?
❍ A. The medication can cause dental staining.
❍ B. The client will need to avoid a high-carbohydrate diet.
❍ C. The client will need a regularly scheduled blood work.
❍ D. The medication can cause problems with drowsiness.
134. Assessment of a newborn male reveals that the infant has hypospadias. The nurse knows that:
❍ A. The infant should not be circumcised.
❍ B. Surgical correction will be done by 6 months of age.
❍ C. Surgical correction is delayed until 6 years of age.
❍ D. The infant should be circumcised to facilitate voiding.
135. The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking oil is not suggested for the client on a lowcholesterol diet?
❍ A. Safflower oil
❍ B. Sunflower oil
❍ C. Coconut oil
❍ D. Canola oil
136. A client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal:
❍ A. A weight loss of 2 pounds in 1 day
❍ B. A serum creatinine 1.25mg/dL
❍ C. Urinary output of 50mL/hr
❍ D. Rising blood pressure
137. A client is admitted with a blood alcohol level of 180mg/dL. The nurse recognizes that the alcohol in the client’s system should be fully metabolized within:
❍ A. 3 hours
❍ B. 5 hours
❍ C. 7 hours
❍ D. 9 hours
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138. The nurse is caring for a client with stage III Alzheimer’s disease. A characteristic of this stage is:
❍ A. Memory loss
❍ B. Failing to recognize familiar objects
❍ C. Wandering at night
❍ D. Failing to communicate
139. The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
❍ A. Take the medication 30 minutes before eating.
❍ B. Report changes in appetite and weight.
❍ C. Wear sunglasses to prevent cataracts.
❍ D. Schedule a time to take the influenza vaccine.
140. The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should:
❍ A. Place the client in a prone position 15–30 minutes twice a day
❍ B. Keep the foot of the bed elevated on shock blocks
❍ C. Place trochanter rolls on either side of the affected leg
❍ D. Keep the client’s leg elevated on two pillows
141. The mother of a 6-month-old asks when her child will have all his baby teeth. The nurse knows that most children have all their primary teeth by age:
❍ A. 12 months
❍ B. 18 months
❍ C. 24 months
❍ D. 30 months
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142. A client with an esophageal tamponade develops symptoms of respiratory distress, including inspiratory stridor. The nurse should give priority to:
❍ A. Applying oxygen at 4L via nasal cannula
❍ B. Removing the tube after deflating the balloons
❍ C. Elevating the head of the bed to 45°
❍ D. Increasing the pressure in the esophageal balloon
143. The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:
❍ A. The third intercostal space right of the sternum
❍ B. The third intercostal space left of the sternum
❍ C. The fourth intercostal space beneath the sternum
❍ D. The fourth intercostal space midclavicular line
144. While caring for a client with cervical cancer, the nurse notes that the radioactive implant is lying in the bed. The nurse should:
❍ A. Place the implant in a biohazard bag and return it to the lab
❍ B. Give the client a pair of gloves and ask her to reinsert the implant
❍ C. Use tongs to pick up the implant and return it to a lead-lined container
❍ D. Discard the implant in the commode and double-flush
145. The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The nurse should
❍ A. Tell the client to avoid a tub bath for 48 hours
❍ B. Tell the client to expect clay-colored stools
❍ C. Tell the client that she can expect lower abdominal pain for the next week
❍ D. Tell the client to report pain in the back or shoulders
146. A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client:
❍ A. To drink additional fluids throughout the day
❍ B. To avoid contact sports for 1–2 months
❍ C. To have a snack twice a day to prevent hypoglycemia
❍ D. To continue antibiotic therapy for 6 months
147. An adolescent with cystic fibrosis has an order for pancreatic enzyme replacement. The nurse knows that the medication should be given:
❍ A. At bedtime
❍ B. With meals and snacks
❍ C. Twice daily
❍ D. Daily in the morning
148. The doctor has prescribed a diet high in vitamin B12 for a client with pernicious anemia. Which foods are good sources of B12?
❍ A. Meat, eggs, dairy products
❍ B. Peanut butter, raisins, molasses
❍ C. Broccoli, cauliflower, cabbage
❍ D. Shrimp, legumes, bran cereals
149. A client with hypertension has begun an aerobic exercise program. The nurse should tell the client that the recommended exercise regimen should begin slowly and build up to:
❍ A. 20–30 minutes three times a week
❍ B. 45 minutes two times a week
❍ C. 1 hour four times a week
❍ D. 1 hour two times a week
150. A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
❍ A. Aldactone (spironolactone)
❍ B. Demadex (torsemide)
❍ C. Dyrenium (triamterene)
❍ D. Midamor (amiloride hydrochloride
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