Comprehensive NCLEX-RN Practice Exam

#6 note: contains rationale latest edition

2024

1. Question

Category: Reduction of Risk Potential

After cardiac surgery, a client’s blood pressure measures 126/80 mm Hg. Nurse
Katrina determines that mean arterial pressure (MAP) is which of the following?

• A. 46 mm Hg

• B. 80 mm Hg

• C. 95 mm Hg

• D. 90 mm Hg
Correct Answer: C. 95 mm Hg
Use the following formula to calculate MAP
MAP = systolic + 2 (diastolic)
MAP = 126 mm Hg + 2 (80 mm Hg)
MAP = 286 mm Hg
MAP = 95 mm Hg
• Option A: 46 mmHg is incorrect according to the calculations.
• Option B: 80 mmHg is inadequate according to the formula used in
the computation.
• Option D: 90 mmHg is incorrect according to the computation using
the formula of mean arterial pressure.
2. Question

Category: Physiological Adaptation

A female client arrives at the emergency department with chest and stomach pain
and a report of black tarry stool for several months. Which of the following orders
should the nurse Oliver anticipate?
 • A. Cardiac monitor, oxygen, creatine kinase and lactate dehydrogenase
levels

• B. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin

split product values

• C. Electrocardiogram, complete blood count, testing for occult blood,

comprehensive serum metabolic panel

• D. Electroencephalogram, alkaline phosphatase, and aspartate

aminotransferase levels, basic serum metabolic panel
Correct Answer: C. Electrocardiogram, complete blood count, testing for
occult blood, comprehensive serum metabolic panel.
An electrocardiogram evaluates the complaints of chest pain, laboratory tests
determine anemia, and the stool test for occult blood determines blood in the
stool.
• Option A: Cardiac monitoring, oxygen, and creatine kinase, and
lactate dehydrogenase levels are appropriate for a cardiac primary
problem. A basic metabolic panel and alkaline phosphatase and
aspartate aminotransferase levels assess liver function.
• Option B: Prothrombin time, partial thromboplastin time, fibrinogen
and fibrin split products are measured to verify bleeding dyscrasias.
• Option D: An electroencephalogram evaluates brain electrical
activity.
3. Question

Olivia had coronary artery bypass graft (CABG) surgery 3 days ago. Which of the
following conditions is suspected by the nurse when a decrease in platelet count
from 230,000 ul to 5,000 ul is noted?

• A. Pancytopenia

• B. Idiopathic thrombocytopenic purpura (ITP)

• C. Disseminated intravascular coagulation (DIC)

• D. Heparin-associated thrombosis and thrombocytopenia (HATT)

Correct Answer: D. Heparin-associated thrombosis and thrombocytopenia
(HATT)
HATT may occur after CABG surgery due to heparin use during surgery.
• Option B: ITP is a bleeding condition of unknown cause in which the
blood fails to clot adequately because of a low circulating platelet
count and a shortened platelet lifespan.
• Option C: Although DIC causes platelet aggregation and bleeding, it
is common in a client after revascularization surgery.
• Option A: Pancytopenia is a reduction in all blood cells.

4. Question

Category: Pharmacological and Parenteral Therapies

Which of the following drugs would be ordered by the physician to improve the
platelet count in a male client with idiopathic thrombocytopenic purpura (ITP)?

• A. Acetylsalicylic acid (ASA)

• B. Corticosteroids

• C. Methotrexate

• D. Vitamin K
Correct Answer: B. Corticosteroids
Corticosteroid therapy can decrease antibody production and phagocytosis of
the antibody-coated platelets, retaining more functioning platelets.
• Option A: ASA blocks prostaglandin synthesis. Inhibition of COX-1
results in the inhibition of platelet aggregation for about 7-10 days
(average platelet lifespan).
• Option C: Methotrexate inhibits enzymes responsible for nucleotide
synthesis which prevents cell division and leads to anti-inflammatory
actions. It causes thrombocytopenia.
• Option D: Vitamin K is used to treat an excessive anticoagulate state
from warfarin overload.
5. Question

Category: Reduction of Risk Potential

A female client is scheduled to receive a heart valve replacement with a porcine
valve. Which of the following types of transplant is this?

• A. Allogeneic
 • B. Autologous

• C. Syngeneic

• D. Xenogeneic
Correct Answer: D. Xenogeneic
A xenogeneic transplant is between a human and another species.
• Option A: Allogeneic transplant is between two humans,
• Option B: Autologous is a transplant from the same individual.
• Option C: A syngeneic transplant is between identical twins.

6. Question

Category: Physiological Adaptation

Marco falls off his bicycle and injures his ankle. Which of the following actions
shows the initial response to the injury in the extrinsic pathway?

• A. Release of Calcium

• B. Release of tissue thromboplastin

• C. Conversion of factors XII to factor XIIa

• D. Conversion of factor VIII to factor VIIIa

Correct Answer: B. Release of tissue thromboplastin
Tissue thromboplastin is released when damaged tissue comes in contact with
clotting factors.
• Option A: Calcium is released to assist the conversion of factors X to
Xa.
• Option C: Conversion of factors XII to XIIa are part of the intrinsic
pathway.
• Option D: Conversion factors VIII to VIIIa are part of the intrinsic
pathway.
7. Question

Category: Physiological Adaptation

Instructions for a client with systemic lupus erythematosus (SLE) would include
information about which of the following blood dyscrasias?

• A. Dressler’s syndrome
 • B. Polycythemia

• C. Essential thrombocytopenia

• D. Von Willebrand’s disease

Correct Answer: C. Essential thrombocytopenia
Essential thrombocytopenia is linked to immunologic disorders, such as SLE and
the human immunodeficiency virus.
• Option A: Dressler’s syndrome is pericarditis that occurs after
myocardial infarction and isn’t linked to SLE.
• Option B: Moderate to severe anemia is associated with SLE, not
polycythemia. It is found in about 50% of patients, with anemia of
chronic disease being the most common form.
• Option D: Von Willebrand disease is a blood disorder in which the
blood doesn’t clot properly. Blood contains many proteins that help
the body stop bleeding. One of these proteins is called von
Willebrand factor.
8. Question

Category: Reduction of Risk Potential

The nurse is aware that the following symptom is most commonly an early
indication of stage 1 Hodgkin’s disease?

• A. Pericarditis

• B. Night sweat

• C. Splenomegaly

• D. Persistent hypothermia
Correct Answer: B. Night sweat
In stage 1, symptoms include a single enlarged lymph node (usually), unexplained
fever, night sweats, malaise, and generalized pruritus.
• Option A: Pericarditis refers to the inflammation of the pericardium,
two thin layers of a sac-like tissue that surround the heart, hold it in
place, and help it work. Pericarditis isn’t associated with Hodgkin’s
disease, nor is hypothermia. Moreover, splenomegaly and
pericarditis aren’t symptoms.
 • Option C: The spleen is involved in 20%-30% of cases of Hodgkin’s
disease. Patients are usually asymptomatic.
• Option D: Persistent hypothermia is associated with Hodgkin’s but
isn’t an early sign of the disease.
9. Question

Category: Reduction of Risk Potential

Francis with leukemia has neutropenia. Which of the following functions must be
frequently assessed?

• A. Blood pressure

• B. Bowel sounds

• C. Heart sounds

• D. Breath sounds
Correct Answer: D. Breath sounds
Pneumonia, both viral and fungal, is a common cause of death in clients with
neutropenia, so frequent assessment of respiratory rate and breath sounds is
required.
• Option A: Blood pressure should be monitored regularly, but it is
not a priority with neutropenia.
• Option B: Assessing bowel sounds is not associated with
neutropenia. Leukemia may affect the small and large bowel and
they are usually hemorrhagic or infiltrative.
• Option C: Although assessing heart sounds is important, it won’t
help detect neutropenia. Patients with acute leukemia develop a
higher rate of congestive heart failure than patients with other
cancers.
10. Question

Category: Physiological Adaptation

The nurse knows that neurologic complications of multiple myeloma (MM)
usually involve which of the following body systems?

• A. Brain

• B. Muscle spasm
 • C. Renal dysfunction

• D. Myocardial irritability
Correct Answer: B. Muscle spasm
Back pain or paresthesia in the lower extremities may indicate impending spinal
cord compression from a spinal tumor. This should be recognized and treated
promptly as the progression of the tumor may result in paraplegia.
• Option A: The reasons underlying the relative paucity of CNS
invasion by multiple myeloma in comparison with other tumors,
whether solid or hematological, remain unknown, but this
phenomenon might be the result of underlying biological
characteristics, or lack thereof, of malignant plasma cells.
• Option C: In some cases, renal impairment is caused by the
accumulation and precipitation of light chains, which form casts in
the distal tubules, resulting in renal obstruction.
• Option D: Some of the treatments used in MM may also affect
cardiovascular health, however, with careful risk assessment,
monitoring, and prophylactic therapy, many of these cardiovascular
complications can be managed or treated successfully.
11. Question

Category: Physiological Adaptation

Nurse Patricia is aware that the average length of time from human
immunodeficiency virus (HIV) infection to the development of acquired
immunodeficiency syndrome (AIDS)?

• A. Less than 5 years

• B. 5 to 7 years

• C. 10 years

• D. More than 10 years

Correct Answer: C. 10 years
Epidemiologic studies show the average time from initial contact with HIV to the
development of AIDS is 10 years. The interval from HIV infection to the diagnosis
of AIDS ranges from about 9 months to 20 years or longer, with a median of 12
years.
 • Option A: Less than 5 years is too short a time for the development
of AIDS.
• Option B: 5 to 7 years is not the average time when an HIV infection
develops into AIDS.
• Option D: More than 10 years is more than the average time for HIV
to develop into AIDS.
12. Question

Category: Reduction of Risk Potential

An 18-year-old male client admitted with heat stroke begins to show signs of
disseminated intravascular coagulation (DIC). Which of the following laboratory
findings is most consistent with DIC?

• A. Low platelet count

• B. Elevated fibrinogen levels

• C. Low levels of fibrin degradation products

• D. Reduced prothrombin time

Correct Answer: A. Low platelet count
In DIC, platelets and clotting factors are consumed, resulting in microthrombi and
excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin
time increases.
• Option B: Severe, rapidly evolving DIC is diagnosed by
demonstrating thrombocytopenia, an elevated partial
thromboplastin time and prothrombin time, increased levels of
plasma D-dimers, and a decreasing plasma fibrinogen level.
• Option C: Fibrin degradation products increase as fibrinolysis takes
place.
• Option D: Both PT and aPTT seem prolonged in about 50% of DIC
cases which is attributed to the consumption of coagulation factors
but can also be prolonged in impaired synthesis of coagulation
factors and in massive bleeding.
13. Question

Category: Physiological Adaptation

Mario comes to the clinic complaining of fever, drenching night sweats, and
unexplained weight loss over the past 3 months. Physical examination reveals a
single enlarged supraclavicular lymph node. Which of the following is
the most probable diagnosis?

• A. Influenza

• B. Sickle cell anemia

• C. Leukemia

• D. Hodgkin’s disease
Correct Answer: D. Hodgkin’s disease
Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph
node enlargement.
• Option A: The incubation period ranges from 1 to 4 days. Peak virus
shedding usually occurs from 1 day before the onset of symptoms to
3 days after.
• Option B: Clients with sickle cell anemia manifest signs and
symptoms of chronic anemia with pallor of the mucous membrane,
fatigue, and decreased tolerance for exercise; they don’t show fever,
night sweats, weight loss or lymph node enlargement.
• Option C: In some cases, the signs of leukemia may include
noticeable swelling of the neck, armpit, or groin. This occurs when
leukemia has spread to the lymph nodes.
14. Question

Category: Physiological Adaptation

A male client with a gunshot wound requires an emergency blood transfusion.
His blood type is AB negative. Which blood type would be the safest for him to
receive?

• A. AB Rh-positive

• B. A Rh-positive

• C. A Rh-negative

• D. O Rh-positive
Correct Answer: C. A Rh-negative
Human blood can sometimes contain an inherited D antigen. Persons with the D
antigen have Rh-positive blood type; those lacking the antigen have Rh-negative
blood. It’s important that a person with Rh-negative blood receives Rh-negative
blood.
• Option A: A person with Rh-negative blood should also receive Rh-
negative blood.
• Option B: If Rh-positive blood is administered to an Rh-negative
person, the recipient develops anti-Rh agglutinins, and subsequent
transfusions with Rh-positive blood may cause serious reactions with
clumping and hemolysis of red blood cells.
• Option D: This blood type is still not compatible because it is Rh-
positive.
15. Question

Category: Health Promotion and Maintenance

Stacy was diagnosed with acute lymphoid leukemia (ALL). She was discharged
from the hospital following her chemotherapy treatments. Which statement of
Stacy’s mother indicated that she understands when she will contact the
physician?

• A. “I should contact the physician if Stacy has difficulty in sleeping”.

• B. “I will call my doctor if Stacy has persistent vomiting and diarrhea”.

• C. “My physician should be called if Stacy is irritable and unhappy”.

• D. “Should Stacy have continued hair loss, I need to call the doctor”.
Correct Answer: B. “I will call my doctor if Stacy has persistent vomiting and
diarrhea”.
Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of
toxicity and the patient should stop the medication and notify the healthcare
provider.
• Option A: Oftentimes, chemotherapy drugs cause patients to feel
tired and sleepy throughout the day. Therefore, patients on
chemotherapy can end up napping or sleeping during the day and
that leads to difficulty sleeping at night or through the night.
• Option C: Chemotherapy medications can directly impact the way
people feel emotionally and physically.
 • Option D: Chemotherapy drugs are powerful medications that
attack rapidly growing cancer cells. Unfortunately, these drugs also
attack other rapidly growing cells in the body, including those in the
hair roots.
16. Question

Category: Psychosocial Integrity

Molly Sue is diagnosed with acute lymphoid leukemia (ALL) and beginning
chemotherapy. Her mother states to the nurse that it is hard to see Molly Sue
with no hair. The best response for the nurse is:

• A. “Molly Sue looks very nice wearing a hat”.

• B. “You should not worry about her hair, just be glad that she is alive”.

• C. “Yes, it is upsetting. But try to cover up your feelings when you are
with her or else she may be upset”.

• D. “This is only temporary; Molly Sue will re-grow new hair in 3-6
months but may be different in texture”.
Correct Answer: D. “This is only temporary; Stacy will re-grow new hair in 3-
6 months but may be different in texture”.
This is the appropriate response. The nurse should help the mother how to cope
with her own feelings regarding the child’s disease so as not to affect the child
negatively. When the hair grows back, it is still of the same color and texture.
• Option A: It can be an option for the client to use a hat, but the
nurse should be open about explanations regarding the side effects
of chemotherapy.
• Option B: Avoid reassuring the client. Statements of fact would be a
good response.
• Option C: The mother should be open and honest with the child,
and providing an honest and true response would be a big help to
both of them.
17. Question

Category: Basic Care and Comfort

Brittany who is undergoing chemotherapy for her throat cancer is experiencing
stomatitis. To promote oral hygiene and comfort, the nurse-in-charge should:
 1. Provide frequent mouthwash with normal saline.

• A. Provide frequent mouthwash with normal saline.

• B. Apply viscous Lidocaine to oral ulcers as needed.

• C. Use lemon glycerine swabs every 2 hours.

• D. Rinse mouth with Hydrogen Peroxide.

Correct Answer: B. Apply viscous Lidocaine to oral ulcers as needed.
Stomatitis can cause pain and this can be relieved by applying topical anesthetics
such as lidocaine before mouth care.
• Option A: Before providing oral care, ensure that the patient is
comfortable with the procedure first.
• Option C: Use saline solution mixed with equal parts of water or
hydrogen peroxide or oral care.
• Option D: When the patient is already comfortable, the nurse can
proceed with providing the patient with oral rinses of saline solution
mixed with equal parts of water or hydrogen peroxide mixed water
in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.
18. Question

Category: Management of Care

During the administration of chemotherapy agents, Nurse Oliver observed that
the IV site is red and swollen when the IV is touched Stacy shouts in pain.
The first nursing action to take is:

• A. Notify the physician.

• B. Flush the IV line with saline solution.

• C. Immediately discontinue the infusion.

• D. Apply an ice pack to the site, followed by warm compress.

Correct Answer: C. Immediately discontinue the infusion.
Edema or swelling at the IV site is a sign that the needle has been dislodged and
the IV solution is leaking into the tissues causing the edema. The patient feels
pain as the nerves are irritated by pressure and the IV solution. The first action of
the nurse would be to discontinue the infusion right away to prevent further
edema and other complications.
• Option A: After discontinuing the infusion, the nurse should notify
the physician.
• Option B: Flushing may aggravate the edema since the IV cannula
might be dislodged.
• Option D: Compresses may be given as indicated by the physician.

19. Question

Category: Physiological Adaptation

The term “blue bloater” refers to a male client which of the following conditions?

• A. Adult respiratory distress syndrome (ARDS)

• B. Asthma

• C. Chronic obstructive bronchitis

• D. Emphysema
Correct Answer: C. Chronic obstructive bronchitis
Clients with chronic obstructive bronchitis appear bloated; they have large barrel
chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis.
• Option A: Clients with ARDS are acutely short of breath and
frequently need intubation for mechanical ventilation and large
amounts of oxygen.
• Option B: Clients with asthma don’t exhibit characteristics of chronic
disease.
• Option D: Clients with emphysema appear pink and cachectic.

20. Question

Category: Physiological Adaptation

The term “pink puffer” refers to the female client with which of the following
conditions?

• A. Adult respiratory distress syndrome (ARDS)

• B. Asthma

• C. Chronic obstructive bronchitis

 • D. Emphysema
Correct Answer: D. Emphysema
Because of the large amount of energy it takes to breathe, clients with
emphysema are usually cachectic. They’re pink and usually breathe through
pursed lips, hence the term “puffer.”
• Option A: Clients with ARDS are usually acutely short of breath.
• Option B: Clients with asthma don’t have any particular
characteristics.
• Option C: Clients with chronic obstructive bronchitis are bloated and
cyanotic in appearance.
21. Question

Category: Reduction of Risk Potential

Jose is in danger of respiratory arrest following the administration of a narcotic
analgesic. An arterial blood gas value is obtained. Nurse Oliver would expect the
paco2 to be which of the following values?

• A. 15 mm Hg

• B. 30 mm Hg

• C. 40 mm Hg

• D. 80 mm Hg
Correct Answer: D. 80 mm Hg
A client about to go into respiratory arrest will have inefficient ventilation and will
be retaining carbon dioxide. The value expected would be around 80 mm Hg. All
other values are lower than expected.
• Option A: 15 mmHg is a low value for a client about to go into
respiratory arrest.
• Option B: 30 mmHg is lower than the expected value because of
inefficient ventilation.
• Option C: 40 mmHg is still less than the expected value for a client
who is about to go into respiratory arrest.
22. Question

Category: Reduction of Risk Potential

Timothy’s arterial blood gas (ABG) results are as follows; pH 7.16; Paco2 80 mm
Hg; Pao2 46 mm Hg; HCO3- 24 mEq/L; Sao2 81%. This ABG result represents
which of the following conditions?

• A. Metabolic acidosis

• B. Metabolic alkalosis

• C. Respiratory acidosis

• D. Respiratory alkalosis
Correct Answer: C. Respiratory acidosis
Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is
normal, the client has respiratory acidosis.
• Option A: If the HCO3- was below 22 mEq/L the client would have
metabolic acidosis.
• Option B: The result of the ABG is less than 7.35, which makes
metabolic alkalosis incorrect.
• Option D: The pH is less than 7.35, academic, which eliminates
respiratory alkalosis as a possibility.
23. Question

Category: Physiological Adaptation

Norma has started a new drug for hypertension. Thirty minutes after she takes
the drug, she develops chest tightness and becomes short of breath and
tachypnea. She has a decreased level of consciousness. These signs indicate
which of the following conditions?

• A. Asthma attack

• B. Pulmonary embolism

• C. Respiratory failure

• D. Rheumatoid arthritis
Correct Answer: C. Respiratory failure
The client was reacting to the drug with respiratory signs of impending
anaphylaxis, which could lead to eventually respiratory failure.
 • Option A: The symptoms may look like an asthma attack, but it may
change because of the new drug ingested.
• Option B: Although the signs are also related to a pulmonary
embolism, consider the new drug first.
• Option D: Rheumatoid arthritis is an autoimmune and inflammatory
disease, which means that the immune system attacks healthy cells
in the body by mistake, causing inflammation in the affected parts of
the body.
24. Question

Category: Reduction of Risk Potential

Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out
cirrhosis of the liver which laboratory test indicates liver cirrhosis?

• A. Decreased red blood cell count

• B. Decreased serum acid phosphatase level

• C. Elevated white blood cell count

• D. Elevated serum aminotransferase

Correct Answer: D. Elevated serum aminotransferase
Hepatic cell death causes the release of liver enzymes alanine aminotransferase
(ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) into
the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver
characterized by generalized inflammation and fibrosis of the liver tissues.
• Option A: Decreased red blood cell count may indicate anemia.
• Option B: Serum acid phosphatase is an enzyme that acts to liberate
phosphate under acidic conditions. Until now, low values cannot be
determined with certainty.
• Option C: A high white blood cell count usually indicates increased
production of white blood cells to fight infection.
25. Question

Category: Reduction of Risk Potential

The biopsy of Mr. Gonzales confirms the diagnosis of cirrhosis. Mr. Gonzales is at
increased risk for excessive bleeding primarily because of:
 • A. Impaired clotting mechanism

• B. Varix formation

• C. Inadequate nutrition

• D. Trauma of invasive procedure

Correct Answer: A. Impaired clotting mechanism
Cirrhosis of the liver results in decreased Vitamin K absorption and formation of
clotting factors resulting in impaired clotting mechanism.
• Option B: Esophageal varices sometimes form when blood flow to
the liver is blocked, most often by scar tissue in the liver caused by
liver disease.
• Option C: Inadequate nutrition alone cannot cause excessive
bleeding in cirrhosis.
• Option D: An invasive procedure may cause trauma that may result
in bleeding, but the client has not yet undergone any invasive
procedure.
26. Question

Category: Physiological Adaptation

Mr. Jay develops hepatic encephalopathy. Which clinical manifestation
is most common with this condition?

• A. Increased urine output

• B. Altered level of consciousness

• C. Decreased tendon reflex

• D. Hypotension
Correct Answer: B. Altered level of consciousness
Changes in behavior and level of consciousness are the first signs of hepatic
encephalopathy. Hepatic encephalopathy is caused by liver failure and develops
when the liver is unable to convert protein metabolic product ammonia to urea.
This results in accumulation of ammonia and other toxic in the blood that
damages the cells.
 • Option A: The main cause of renal dysfunction in inpatients with
liver disease is prerenal failure; specifically, the cause is a reduction in
perfusion of the kidneys.
• Option C: It must be emphasized that the flapping tremor of the
extremities is also observed in patients with uremia, pulmonary
insufficiency, and barbiturate toxicity.
• Option D: A diseased liver can cause portal hypertension, which is
high blood pressure in the portal vein. The portal vein supplies the
liver with blood. Over time, this pressure causes blood vessels to
grow, called collateral blood vessels. These vessels act as channels to
divert the blood under high pressure.
27. Question

Category: Pharmacological and Parenteral Therapies

Patrick who is diagnosed with liver cirrhosis is experiencing symptoms of hepatic
encephalopathy. The physician ordered 50 ml of Lactulose p.o. every 2 hours.
Patrick suddenly develops diarrhea. The nurse best action would be:

• A. “I’ll see if your physician is in the hospital”.

• B. “Maybe you’re reacting to the drug; I will withhold the next dose”.

• C. “I’ll lower the dosage as ordered so the drug causes only 2 to 4

stools a day”.

• D. “Frequently, bowel movements are needed to reduce sodium level”.

Correct Answer: C. “I’ll lower the dosage as ordered so the drug causes only
2 to 4 stools a day”.
Lactulose is given to a patient with hepatic encephalopathy to reduce absorption
of ammonia in the intestines by binding with ammonia and promoting more
frequent bowel movements. If the patient experiences diarrhea, it indicates
overdosage and the nurse must reduce the amount of medication given to the
patient. The stool will be mushy or soft. Lactulose is also very sweet and may
cause cramping and bloating.
• Option A: The nurse may inform the physician so that he may order
a lower dosage.
• Option B: Withholding the next dose is unnecessary; the nurse may
lower the dosage as ordered.
 • Option D: Lactulose, in this case, is given to reduce absorption of
ammonia in the intestines.
28. Question

Category: Physiological Adaptation

Which of the following groups of symptoms indicates a ruptured abdominal
aortic aneurysm?

• A. Lower back pain, increased blood pressure, decreased red blood cell
(RBC) count, increased white blood (WBC) count.

• B. Severe lower back pain, decreased blood pressure, decreased RBC

count, increased WBC count.

• C. Severe lower back pain, decreased blood pressure, decreased RBC

count, decreased RBC count, decreased WBC count.

• D. Intermittent lower back pain, decreased blood pressure, decreased

RBC count, increased WBC count.
Correct Answer: B. Severe lower back pain, decreased blood pressure,
decreased RBC count, increased WBC count.
Severe lower back pain indicates an aneurysm rupture, secondary to pressure
being applied within the abdominal cavity. When rupture occurs, the pain is
constant because it can’t be alleviated until the aneurysm is repaired. Blood
pressure decreases due to the loss of blood. After the aneurysm ruptures, the
vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t
increase. For the same reason, the RBC count has decreased – not increased. The
WBC count increases as cells migrate to the site of injury.
• Option A: The pain is severe due to the ruptured aneurysm; the
blood pressure is decreased due to blood loss.
• Option C: The increase in WBC count is due to the cells migrating to
the site of the injury.
• Option D: The pain in a ruptured aneurysm is constant and can only
be alleviated if the aneurysm is repaired.
29. Question

Category: Reduction of Risk Potential

After undergoing a cardiac catheterization, Tracy has a large puddle of blood
under his buttocks. Which of the following steps should the nurse take first?
 • A. Call for help.

• B. Obtain vital signs.

• C. Ask the client to “lift up”.

• D. Apply gloves and assess the groin site.

Correct Answer: D. Apply gloves and assess the groin site.
Observing standard precautions is the first priority when dealing with any blood
fluid. Assessment of the groin site is the second priority. This establishes where
the blood is coming from and determines how much blood has been lost. The
goal in this situation is to stop the bleeding.
• Option A: The nurse would call for help if it were warranted after the
assessment of the situation.
• Option B: After determining the extent of the bleeding, vital signs
assessment is important.
• Option C: The nurse should never move the client, in case a clot has
formed. Moving can disturb the clot and cause rebleeding.
30. Question

Category: Physiological Adaptation

Which of the following treatments is a suitable surgical intervention for a client
with unstable angina?

• A. Cardiac catheterization

• B. Echocardiogram

• C. Nitroglycerin

• D. Percutaneous transluminal coronary angioplasty (PTCA)

Correct Answer: D. Percutaneous transluminal coronary angioplasty (PTCA)
PTCA can alleviate the blockage and restore blood flow and oxygenation.
• Option A: Cardiac catheterization is a diagnostic tool – not a
treatment. It is a procedure used to diagnose and treat certain
cardiovascular conditions.
• Option B: An echocardiogram is a non-invasive diagnostic test. It is
a graphic outline of the heart’s movement.
• Option C: Nitroglycerin is an oral sublingual medication. It is a
vasodilatory drug used primarily to provide relief from anginal chest
pain.