BRAND NEW NCLEX PN TEST BANK EXAM WITH VERIFIED QUESTIONS AND ANSWERS The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to lack of glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast -feeding. Answer D: After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula; thus, answers A, B, and C are incorrect. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis ? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups Answer C: Diarrhea is not common in clients with mouth and throat cancer. All the findings in answers A, B, and D are expected findings. A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included in the plan? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage Answer A: The client with a lung resection will have chest tubes and a drainage -collection device. He probably will not have a tracheostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage. Therefore, answers B, C, and D are incorrect. Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum Answer A: A swelling over the right parietal area is a cephal ohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it is outside the cranium but beneath the periosteum. Answer B, molding, is overlapping of the bones of the cranium and, thus, incorrect. In an swer C, a subdural hematoma, or intracranial bleeding, is ominous and can be seen only on a CAT scan or x -ray. A caput succedaneum, in answer D, crosses the suture line and is edema. The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. “You cannot eat food prepared in a microwave.” B. “You should avoid moving the shoulder on the side of the pacemaker site for 6 weeks.” C. “You should use your cellphone on your right side.” D. “You will not be able to fly on a commercial airliner with the defibrillator in place.” Answer C: The client with an internal defibrillator should learn to use any battery -operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can eat food prepared in the microwave, move his shoulder on the affected side, and fly in an airplane. A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block Answer A: Suctioning can cause a vagal response and bradyca rdia. Answer B is unlikely and, therefore, not most important, although it can occur. Answers C and D can occur as well, but they are less likely. The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client’s level of anxiety B. Evaluation of the client’s exercise tolerance C. Identification of peripheral pulses D. Assessment of bowel sounds and activity Answer C: The assessmen t that is most crucial to the client is the identification of peripheral pulses because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities. Answer A is of lesser concern, answer B is not advised at this time, and answer D is of lesser concern than answer A. A 24-year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? E. Taking the vital signs F. Obtaining the permit G. Explaining the procedure H. Checking the lab work Answer A: The primary responsibility of the nurse is to take the vital signs before any surgery. The actions in answers B, C, and D are the responsibility of the doctor and, therefore, are incorrect for this question.
