NCLEX Comprehensive Review 21-30

NCLEX Comprehensive Review questions with rationales to help you learn from your answer choices.

21. The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied in 0.8mg per milliliter. The nurse should administer how many milliliters of the medication?

A. 0.25mL
B. 0.5mL
C. 1mL
D. 1.25mL

22. If the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to:

A. Pull against the palms
B. Grimace the facial muscles
C. Cross the legs at the ankles
D. Perform Valsalva maneuver

23. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?

A. An elevated white blood cell count
B. An abdominal bruit
C. A negative Babinski reflex
D. Pupils that are equal and reactive to light

24. NCLEX Comprehensive Review about a 4-year-old male who is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:

A. Apply ice to the scrotum
B. Elevate the scrotum on a small pillow
C. Apply heat to the abdominal area
D. Administer a diuretic

25. The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be:

A. A false elevation
B. A false low reading
C. A blood pressure reading that is correct
D. A subnormal finding

26. The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using:

A. Buretrol
B. A tuberculin syringe
C. Intravenous controller
D. Three-way stop-cock

27. The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is:

A. Protein breaks down into blood urea nitrogen and metabolic waste.
B. High protein increases the sodium and potassium levels.
C. A high-protein diet decreases albumin production.
D. A high-protein diet depletes calcium and phosphorous.

28. NCLEX Comprehensive Review about the client who is admitted to the unit after a motor vehicle accident with a temperature of 102 ° F rectally. The nurse is aware that the most likely explanation for the elevated temperature is:

A. There was damage to the hypothalamus.
B. He has an infection from the abrasions to the head and face.
C. He will require a cooling blanket to decrease the temperature.
D. There was damage to the frontal lobe of the brain.

29. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?

A. Occipital
B. Frontal
C. Temporal
D. Parietal

30. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?

A. Measuring five finger breaths under the axilla
B. Measuring 3 inches under the axilla
C. Measuring the client with the elbows flexed 10 °
D. Measuring the client with the crutches 20 inches from the side of the foot

NCLEX Comprehensive Review
Answers and Rationale

21) B
- If the doctor orders 0.4mgm IM and the drug is available in 0.8/ 1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 = 0.5m:. Answers A, C, and D are incorrect.

22) A
- If the nurse cannot elicit the patella reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading. Answers B, C, and D will not help with the test.

- The elevated white blood cell count should be reported because this indicates infection. A bruit will be heard if the client has an aneurysm, and a negative Babinski is normal in the adult, as are pupils that are equal and reactive to light and accommodation; thus, answers B, C, and D are incorrect.

24) B
- The child with nephotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect.

25) A
- NCLEX Comprehensive Review Rationale: If the blood pressure cuff is too small, the result will be a blood pressure that is a false elevation. Answers B, C, and D are incorrect. If the blood pressure cuff is too large, a false low will result. Answers C and D have basically the same meaning.

26) B
- To safely administer heparin, the nurse should obtain an infusion controller. Too rapid infusion of heparin can result in hemorrhage. Answers A, C, and D are incorrect. It is not necessary to have a buretrol, an infusion filter, or a three-way stop-cock.

27) A
- A low-protein diet is required because protein breaks down into nitrogenous waste and causes an increased workload on the kidneys. Answers B, C, and D are incorrect.

28) A
- Damage to the hypothalamus can result in an elevated temperature because this portion of the brain helps to regulate body temperature. Answers B, C, and D are incorrect because there is no data to support the possibility of an infection, a cooling blanket might not be required, and the frontal lobe is not responsible for regulation of the body temperature.

29) C
- The temporal lobe is responsible for taste, smell, and hearing. The occipital lobe is responsible for vision. The frontal lobe is responsible for judgment, foresight, and behavior. The parietal lobe is responsible for ideation, sensory functions, and language. Therefore, answers A, B, and D are incorrect.

30) B
- To correctly measure the client for crutches, the nurse should measure approximately 3 inches under the axilla. Answer A allows for too much distance under the arm. The elbows should be flexed approximately 35 °, not 10 °, as stated in answer C. The crutches should be approximately 6 inches from the side of the foot, not 20 inches, as stated in answer D.

After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:

NCLEX Comprehensive Review 1-10

 Or proceed to the next set of questions:

NCLEX Comprehensive Review 31-40