Exam 3 Practice Answers

7/21/2019 Exam 3 Practice Answers

1/11

DISCLAIMER: These questions are from numerous NCLEX sources which will be liste

at the en! There is a "oo chance that the samestyleof questions mi"ht a##ear on the

e$am but #lease be minful that the answer foun here ma% N&T be the e$act same

answer foun on the e$am! 'rocee with caution! (oo luc) an ha##% stu%in"*

Exam 3 Practice Answers

+! A client with T%#e + iabetes mellitus is amitte to an acute care facilit% with

iabetic )etoaciosis! To correct this acute iabetic emer"enc%, which measure

shoul the health care team ta)e first-

Answer: A . Initiate flui re#lacement thera#%

Rationale:The health care team first initiates flui re#lacement thera#% to

#re/ent or treat circulator% colla#se cause b% se/ere eh%ration! Althou"h

iabetic )etoaciosis results from insulin eficienc%, the client must ha/e an

aequate flui /olume before insulin can be aministere0 otherwise, the ru"

won1t circulate throu"hout the bo% effecti/el%! Therefore, insulin aministration

follows flui re#lacement thera#%! Determinin" an correctin" the cause of

iabetic )etoaciosis are im#ortant ste#s, but the client1s conition must be

stabili2e first to #re/ent life3threatenin" com#lications!

4! A client with Aison1s isease comes to the clinic for a follow3u# /isit! 5hen

assessin" this client, the nurse shoul sta% alert for si"ns an s%m#toms of:

Answer: D . Soium an #otassium abnormalities

Rationale:In Aison1s isease, a form of arenocortical h%#ofunction,

alosterone secretion is reuce! Alosterone #romotes soium conser/ation an

#otassium e$cretion! Therefore, alosterone eficienc% increases soium

e$cretion, #reis#osin" the client to h%#onatremia, an inhibits #otassium

e$cretion, #reis#osin" the client to h%#er)alemia! 6ecause alosterone oesn1t

re"ulate calcium, #hos#horus, chlorie, or ma"nesium, an alosterone eficienc%

oesn1t affect le/els of these electrol%tes irectl%!

7! The nurse obtains a fin"erstic) "lucose le/el of 89 m"l from a client newl%

ia"nose with iabetes mellitus! The client is alert an oriente, an the client1s

s)in is warm an r%! ;ow shoul the nurse inter/ene-Answer: C . &btain a re#eat fin"erstic) "lucose le/el

Rationale:The nurse shoul rechec) the fin"erstic) "lucose le/el to /erif% the

ori"inal result because the client isn1t e$hibitin" si"ns of h%#o"l%cemia! The

nurse shoul "i/e the client mil) an a "raham crac)er with #eanut butter or a

"lass of oran"e


2/11

8! A #atient is #rescribe le/oth%ro$ine =S%nthroi> ail%! 5hat is the most

im#ortant instruction to teach for aministration of this ru"-

Answer: C . Call the octor immeiatel% at the onset of #al#itations or

ner/ousness

Rationale:Le/oth%ro$ine =S%nthroi> increases the metabolic rate of bo%tissues! Some serious sie effects inclue cario/ascular colla#se, %srh%thmias,

an tach%caria! 6ecause of these sie effects, clients shoul be instructe not to

ta)e the meication if their #ulse is "reater than +?? beatsmin an to notif% their

#ro/ier of heaaches, ner/ousness, chest #ain, #al#itations, or an% unusual

s%m#toms!

9! A client with se/ere hea trauma sustaine in a car accient is amitte to the

intensi/e care unit! Thirt%3si$ hours later, the client1s urine out#ut suenl% rises

abo/e 4?? mLhour, leain" the nurse to sus#ect iabetes insi#ius! 5hich

laborator% finin"s su##ort the nurse1s sus#icion of iabetes insi#ius-

Answer: D . 6elow3normal urine osmolalit% le/el, abo/e3normal serum

osmolalit% le/el

Rationale:In iabetes insi#ius, e$cessi/e #ol%uria causes ilute urine, resultin"

in a below3normal urine osmolalit% le/el! At the same time, #ol%uria e#letes the

bo% of water, causin" eh%ration that leas to an abo/e3normal serum

osmolalit% le/el! @or the same reasons, iabetes insi#ius oesn1t cause abo/e3

normal urine osmolalit% or below3normal serum osmolalit% le/els!

! A new iabetic is learnin" to aminister his insulin! ;e recei/es +?B of N'; an

+4B of re"ular insulin each mornin"! 5hich of the followin" statements reflects

unerstanin" of the nurse1s teachin"-

Answer: A . 5hen rawin" u# m% insulin, I shoul raw u# the re"ular insulin

first!

Rationale:Re"ular insulin shoul be rawn u# before the N';! The% can be

"i/en to"ether, so there is no nee for two in


3/11

F! 5hen carin" for a client who1s bein" treate for h%#erth%roiism, it1s im#ortant

to:

Answer: C . 6alance the client1s #erios of acti/it% an rest

Rationale:A client with h%#erth%roiism nees to be encoura"e to balance

#erios of acti/it% an rest! Man% clients with h%#erth%roiism are h%#eracti/e

an com#lain of feelin" /er% warm! Consequentl%, it1s im#ortant to )ee# theen/ironment cool an to teach the client how to mana"e his #h%sical reactions to

heat! Clients with h%#oth%roiism . not h%#erth%roiism . com#lain of bein"

col an nee warm clothin" an blan)ets to maintain a comfortable tem#erature!

The% also recei/e th%roi re#lacement thera#%, often feel lethar"ic an slu""ish,

an are #rone to consti#ation! The nurse shoul encoura"e clients with

h%#oth%roiism to be more acti/e to #re/ent consti#ation!

G! The nurse is assessin" a client with Cushin"1s s%nrome! 5hich obser/ation

shoul the nurse re#ort to the #h%sician immeiatel%-

Answer: 6 . An irre"ular a#ical #ulse

Rationale:6ecause Cushin"1s s%nrome causes alosterone o/er#rouction,

which increases urinar% #otassium loss, the isorer ma% lea to h%#o)alemia!

Therefore, the nurse shoul immeiatel% re#ort si"ns an s%m#toms of

h%#o)alemia, such as an irre"ular a#ical #ulse, to the #h%sician! Eema is an

e$#ecte finin" because alosterone o/er#rouction causes soium an flui

retention! Dr% mucous membranes an frequent urination si"nal eh%ration,

which isn1t associate with Cushin"1s s%nrome!

+?! A client is brou"ht to the emer"enc% e#artment in an unres#onsi/e state, an a

ia"nosis of h%#er"l%cemic h%#erosmolar state =;;S> is mae! The nurse woul

immediately#re#are to initiate which antici#ate health care #ro/ier1s

#rescri#tion!

Answer: C . Intra/enous infusion of normal saline

Rationale:The #rimar% "oal of treatment in h%#er"l%cemic h%#erosmolar state

=;;S> is to reh%rate the client to restore flui /olume an to correct electrol%te

eficienc%! Intra/enous flui re#lacement is similar to that aministere in

iabetic )etoaciosis =DHA> an be"ins with I infusion of normal saline!

Re"ular insulin, not N'; insulin, woul be aministere! The use of soium

bicarbonate to correct aciosis is a/oie because it can #reci#itate a further ro#in serum #otassium le/els! Intubation an mechanical /entilation are not require

to treat ;;S!

++! An e$ternal insulin #um# is #rescribe for a client with iabetes an the client

as)s the nurse about the functionin" of the #um#! The nurse bases the res#onse

on which information about the #um#-


4/11

Answer: D . (i/es a small continuous ose of short3uration insulin

subcutaneousl%, an the client can self3aminister a bolus with an aitional ose

from the #um# before each meal

Rationale:An insulin #um# #ro/ies a small continuous ose of short3uration

=ra#i or short3actin"> insulin subcutaneousl% throu"hout the a% an ni"ht, an

the client can self3aminister a bolus with an aitional ose from the #um#

before each meal as neee! Short3uration insulin is use in an insulin #um#!

An e$ternal #um# is not attache sur"icall% to the #ancreas!

+4! A client is amitte to an emer"enc% e#artment, an a ia"nosis of m%$eema

coma is mae! 5hich action woul the nurse #re#are to carr% out initially-

Answer: 6 . Maintain a #atent airwa%

Rationale:The initial nursin" action woul be to maintain a #atent airwa%!

&$%"en woul be aministere, followe b% flui re#lacement, )ee#in" the client

warm, monitorin" /ital si"ns, an aministerin" th%roi hormones b% the

intra/enous route!

+7! A client with t%#e + iabetes mellitus calls the nurse to re#ort recurrent e#isoes

of h%#o"l%cemia with e$ercisin"! 5hich statement b% the client inicates an

aequate unerstanin" of the #ea) action of N'; insulin an e$ercise-

Answer: C 3 The best time for me to e$ercise is mi3to3late afternoon!

Rationale:A h%#o"l%cemic reaction ma% occur in res#onse to increase e$ercise!

Clients shoul a/oi e$ercise urin" the #ea) time of insulin! N'; insulin #ea)s

at 8 to +4 hours0 therefore, afternoon e$ercise ta)es #lace urin" the #ea) of the

meication! tions +, 4, an 8 o not aress #ea) action times!

+8! A client is ia"nose with s%nrome of ina##ro#riate antiiuretic hormone

secretion =SIAD;>! Laborator% results re/eal serum soium le/el +7? mEqL an

urine s#ecific "ra/it% +!?7?! 5hich nursin" inter/ention woul hel# #re/ent

com#lications associate with SIAD;-

Answer: C . Ele/atin" the client1s hea of be to G? e"rees

Rationale:E$cessi/e release of antiiuretic hormone =AD;> isturbs flui an

electrol%te balance in SIAD;! The e$cessi/e AD; causes an inabilit% to e$crete

ilute urine, retention of free water, e$#ansion of e$tracellular flui /olume, an

h%#onatremia! S%m#tomatic treatment be"ins with restrictin" fluis to F??

mLa%! aso#ressin is aministere to clients with iabetes insi#ius, a

conition in which circulatin" AD; is eficient! Ele/atin" the hea of the be

ecreases /ascular return an ecreases atrial3fillin" #ressure, which increases

AD; secretion worsenin" the client1s conition! The client1s soium is low an,

therefore, shouln1t be restricte!


5/11

+9! The nurse is carin" for a #osto#erati/e #arath%roiectom% client! 5hich client

com#laint woul inicate that a life3threatenin" com#lication ma% be e/elo#in",

requirin" notification of the health care #ro/ier immediately-

Answer: A . Lar%n"eal strior

Rationale:Durin" the #osto#erati/e #erio, the nurse carefull% obser/es the

client for si"ns of hemorrha"e, which causes swellin" an com#ression ofa


6/11

+F! In the emer"enc% e#artment urin" initial assessment of a newl%3amitte

#atient with iabetes, the nurse isco/ers all of these finin"s! 5hich finin"

shoul be re#orte to the health care #ro/ier immeiatel%-

Answer: 6 . Ra#i res#irator% rate with ee# ins#irations

Rationale:Ra#i, ee# res#irations =Hussmaul res#irations> are s%m#tomatic of

iabetic )etoaciosis =DHA>! ;ammer toe, as well as numbness an tin"lin", arechronic com#lications associate with iabetes! Decrease sensiti/it% an

swellin" =li#oh%#ertro#h%> occurs at the site of re#eate insulin in


7/11

44! The nurse is amittin" a new client with a ia"nosis of m%$eema! Durin" the

initial assessment, the nurse is most concerne when the client #resents with

which finin"s-

Answer: D 3 6ra%caria an ecrease intellectual function

Rationale:M%$eema is cause b% h%#oth%roiism! Si"ns an s%m#toms of

h%#oth%roiism incluin" slowin" of the heart rate an ecrease intellectualfunctions, such as slurrin" s#eech, im#aire memor%, an inattenti/eness!

;%#ertension, wei"ht loss, heat intolerance, emotional labilit%, an increase

a##etite are all si"ns an s%m#toms of h%#erth%roiism! Corneal ulcerations ma%

be seen in h%#erth%roiism ue to e$o#hthalmos because eema behin the e%e

ma% #re/ent e%elis from closin" com#letel%!

47! A client is scheule for se/eral tests! 5hich test shoul be #erforme after the

th%roi function tests-

Answer: D . Com#ute tomo"ra#h% scan of the hea with contrast

Rationale:Constrast meia contains ioine an can alter th%roi function test

results

48! A nurse is carin" for a client with iabetes insi#ius! 5hich laborator% /alue is

most im#ortant for the nurse to monitor-

Answer: D . Soium

Rationale:Diabetes insi#ius occurs as a result of ecrease release of

antiiuretic hormone, which isturbs flui an electrol%te balance, es#eciall%

soium! Clients nee to be closel% monitore for h%#ernatremia!

49! The nurse is amittin" a client who is ia"nose with untreate Cushin"1s

s%nrome! 5hile #erformin" the initial assessment, the nurse can e$#ect to see

which of the followin" si"ns an s%m#toms-

Answer: A 3 Moon face an truncal obesit%

Rationale:&/er#rouction of arenocortical hormone results in reistribution of

fat, which manifests as a moon face, truncal obesit%, an a buffalo hum#! 5ei"ht

loss an heat intolerance inicate th%roi hormone o/er#rouction! Chan"es in

s)in te$ture an low bo% tem#erature inicate th%roi hormone uner#rouction!

'ol%uria an eh%ration inicate iabetic )etoaciosis!

4! The nurse aministers tamsulosin =@loma$> to a client with beni"n #rostatic

h%#er#lasia =6';>- The nurse is aware that which of the followin" is a #riorit%

assessment-

Answer: A . oiin" #attern

Rationale:The al#ha3arener"ic bloc)er tamsulosin =@loma$> rela$es the smooth

muscle of the blaer nec) an #rostate, so the urinar% /oiin" s%m#toms

=frequenc%, ur"enc%, hesitanc%> of 6'; are reuce in man% clients! These ru"s


8/11

on1t affect the si2e of the #rostate, renal function, or #rouction of metabolism of

testosterone!

4! The client with an ileal conuit will be usin" a resusable a##liance at home! The

nurse shoul teach the client to clean the a##liance routinel% with which #rouct-

Answer: 6 . Soa#Rationale:A reusable a##liance shoul be routinel% cleane with soa# an water

4F! The client is scheule for an intra/enous #%elo"ram =I'> to etermine the

location of the renal calculi! 5hich of the followin" measures woul be most

im#ortant for the nurse to inclue in #retest #re#aration-

Answer: C . Chec)in" the client1s histor% for aller"% to ioine

Rationale:A client scheule for an I' shoul be assesse for aller"ies to

ioine an shellfish! Clients with such aller"ies ma% be aller"ic to the I' %e

an be at ris) for an ana#h%lactic reaction! Aequate flui inta)e is im#ortant

after the e$amination! 6laer s#asms are not common urin" an I'! 6owel#re#aration is im#ortant before an I' to allow /isuali2ation of the ureters an

blaer, but chec)in" for aller"ies is most im#ortant!

4G! A client is com#lainin" of se/ere flan) an abominal #ain! A flate #late of the

abomen shows urolithiasis! 5hich inter/ention is im#ortant-

Answer: A . Strain all urine

Rationale:Brine shoul be straine for calculi an sent to the laborator% for

anal%sis! @lui inta)e of 7 to 8 qt =7 to 8 L> #er a% is encoura"e to flush the

urinar% tract an #re/ent further calculi formation! Ambulation is encoura"e to

hel# #ass the calculi throu"h "ra/it%! A low3calcium iet is recommene to hel##re/ent the formation of calcium calculi!

7?! The nurse is #ro/iin" instruction about s)in care at the stoma site for a client

with an ileal conuit! 5hat is the most im#ortant information for the nurse to

#ro/ie-

Answer: C 3 Clean the s)in aroun the stoma with mil soa# an water an r% it

thorou"hl%

Rationale:Cleanin" the s)in aroun the stoma with mil soa# an water an

r%in" it thorou"hl% hel#s )ee# the area clean from urine, which can irritate the

s)in! Chan"e the a##liance in the earl% mornin" when urine out#ut is less to

ecrease the amount of urine in contact with the s)in! The stoma shoul be

co/ere with a "au2e #a an when chan"in" the a##liance to #re/ent see#a"e of

urine onto the s)in! The face#late or wafer of the a##liance shouln1t be more

than 7 mm lar"er than the stoma to reuce the s)in area in contact with urine!

7+! A client has a transurethral #rostactectom% for beni"n #rostatic h%#ertro#h% an is

currentl% bein" treate with a continuous blaer irri"ation! ;e1s com#lainin" of


9/11

an increase in se/erit% of blaer s#asms! 5hich inter/ention shoul the nurse o

first-

Answer: D 3 Chec) for the #resence of clots an ma)e sure the catheter is

rainin" #ro#erl%

Rationale:6loo cots an bloc)e outflow of the urine can increase s#asms! The

irri"ation shouln1t be sto##e as lon" as the catheter is rainin" because clotswill form! A bellaonna an o#ium su##ositor% shoul be "i/en to relie/e s#asms

but onl% after assessment of the raina"e! &ral anal"esics shoul be "i/en if the

s#asms are unrelie/e b% the bellaonna an o#ium su##ositor%!

74! A client has returne from sur"er% with continuous blaer irri"ation! The nurse

is aware that #ro#er maintenance of a continuous blaer irri"ation s%stem

inclues:

Answer: 6 3 Re"ulatin" irri"ant flow to maintain #in) urine

Rationale:The irri"ant shoul be infuse at a rate fast enou"h to maintain #in)

urine! Re urine inicates inaequate irri"ation an #ossible clot formation!

6laer istension shouln1t occur as lon" as the s%stem is rainin" #ro#erl% an

no clots are obstructin" the outflow of urine! Lea)a"e of urine aroun the

catheter inicates the clot formation on the catheter ti#, neein" manual irri"ation!

The irri"ation shoul be sto##e because of the #otential for clot formation!

77! A client is ia"nose with #rostate cancer! The #h%sician is most li)el% to orer

which test to monitor the client1s #ro"ress-

Answer: C 3 'rostate3s#ecific anti"en ='SA>

Rationale:The 'SA test is use to monitor #rostate cancer #ro"ression0 hi"her

'SA le/els inicate a "reater tumor buren! Serum creatinine le/els ma% su""est

bloc)a"e from an enlar"e #rostate! C6C is use to ia"nose anemia an

#ol%c%themia! Serum #otassium le/els ientif% h%#o)alemia an h%#er)alemia!

78! A sterile urine s#ecimen for culture an sensiti/it% has been orere for a #atient

who has an inwellin" urinar% catheter! ;ow shoul the nurse obtain this

s#ecimen-

Answer: A 3 5ithraw se/eral millimeters of urine from the #ort on the

collection tubin", usin" a s%rin"e an neele

Rationale: 5hen it is necessar% to collect a urine s#ecimen from a #atient with aninwellin" catheter, it shoul be obtaine from the catheter itself usin" the s#ecial

#ort for s#ecimens! A s#ecimen from the collectin" rece#tacle =raina"e ba">

ma% not be fresh urine an coul result in an inaccurate anal%sis! A #atient1s

catheter woul not be remo/e for the sole #ur#ose of obtainin" a urine s#ecimen!


10/11

79! The nurse is #ro/iin" ischar"e instructions for a client treate for acute

#%elone#hritis! 5hat is the most im#ortant information for the nurse to inclue-

Answer: 6 3 Return for follow3u# urine cultures

Rationale:The client nees to return for follow3u# urine cultures because

bacteriauria ma% be #resent but as%m#tomatic! Inta)e of air% #roucts won1t

contribute to #%elone#hritis! Antibiotics nee to be ta)en for the full course ofthera#% re"arless of s%m#toms! '%elone#hritis t%#icall% recurs as a rela#se or

new infection an frequentl% recurs within 4 wee)s of com#letin" thera#%!

7! A client who will ha/e his last chemothera#% c%cle in ++ a%s becomes

neutro#enic! The client unerstans his conition when he states:

Answer: A 3 I1ll monitor m% tem#erature frequentl% an "o to the nearest

emer"enc% e#artment if m% tem#erature rises abo/e +??!8K@!

Rationale:The client unerstans his neutro#enic state when he states that he1ll

monitor his tem#erature frequentl% an "o to the emer"enc% e#artment if his

tem#erature rises abo/e +??!8K@! Neutro#enic clients shoul a/oi crows, eatin"

fresh fruits an /e"etables, an wor)in" in the "aren . all of which #lace the

client at ris) for infection!

7! A client recei/e chemothera#% 48 hours a"o! 5hich #recautions are necessar%

when carin" for the client-

Answer: C 3 5ear #ersonal #rotecti/e equi#ment when hanlin" bloo, bo%

fluis, an feces

Rationale:Chemothera#% ru"s are #resent in the waste an bo% fluis of

clients for 8F hours after aministration! The nurse shoul wear #ersonal

#rotecti/e equi#ment when hanlin" bloo, bo% fluis, or feces! (lo/es offer

minimal #rotection a"ainst e$#osure! The nurse shoul wear a face shiel, "own,

an "lo/es when e$#osure to bloo or bo% flui is li)el%! 'lacin" incontinence

#as in the re"ular trashcan an #ro/iin" a urinal or be#an on1t #rotect the

nurse carin" for the client!

7F! A client uner"oes a bio#s% of a sus#icious lesion! The bio#s% re#ort classifies

the lesion accorin" to the TNM sta"in" s%stem as follows: TIS, N?, M?! 5hat

oes this classification mean-

Answer: 6 3 Carcinoma in situ, no abnormal re"ional l%m#h noes, an no

e/ience of istant metastasis

Rationale:TIS, N?, M? enotes carcinoma in situ, no abnormal re"ional l%m#h

noes, an no e/ience of istant metastasis! No e/ience of #rimar% tumor, no

abnormal re"ional l%m#h noes, an no e/ience of istant metastasis is classifie

as T?, N?, M?! If the tumor an re"ional l%m#h noes can1t be assesse an no

e/ience of metastasis e$ists, the lesion is classifie as TX, NX, M?! A

#ro"ressi/e increase in tumor si2e, no emonstrable metastasis of the re"ional


11/11

l%m#h noes, an ascenin" e"rees of istant metastasis is classifie as T+, T4,

T7, or T80 N?0 an M+, M4, or M7!

7G! After cancer chemothera#%, a client e$#eriences nausea an /omitin"! The nurse

shoul assi"n hi"hest #riorit% to which inter/ention-

Answer: C 3 Aministerin" metoclo#ramie =Re"lan> an e$amethasone

=Decaron> as #rescribe!

Rationale: Aministerin" an antiemetic, such as metoclo#ramie, an an anti3

inflammator% a"ent, such as e$amethasone, ma% reuce the se/erit% of

chemothera#%3inuce nausea an /omitin"! This, in turn, hel#s #re/ent

eh%ration, a common com#lication of chemothera#%! The other o#tions are less

li)el% to achie/e this outcome!

8?! 5hich statement b% a client uner"oin" e$ternal raiation thera#% inicates the

nee for further teachin"-

Answer: D 3 I will e$#ose m% famil% members to raiation!

Rationale:The client uner"oin" e$ternal raiation thera#% requires further

teachin" when he /oices a concern that he mi"ht e$#ose his famil% to raiation!

Internal raiation, not e$ternal raiation, #oses a ris) to the client1s famil%! The

client requires no further teachin" if he states that he shoul wash his s)in with

mil soa# an water, wear #rotecti/e clothin" when outsie, an a/oi usin" a

heathin" #a!

Exam 3 Practice Answers

Documents

Transcript of Exam 3 Practice Answers