Nursing Exam Questions and Answers, Exams of Nursing

Download Nursing Exam Questions and Answers and more Exams Nursing in PDF only on Docsity! NCLEX 70 practice exam 1 and rationales Which client can best be assigned to the newly licensed practical nurse? a. The client receiving chemotherapy b. The client post-coronary bypass c. The client the TURP d. The client with diverticulitis - ✔ ✔ D - The client with diverticulitis Which laboratory rest would be the least effective in making the diagnosis of a myocardial infarction? a) AST b) Troponin c) CK-MB d) Myoglobin - ✔ ✔ A - AST Which of the following post-operative diets is most appropriate for the client who has had a hermorroidectomy? a) High-fiber b) Low-residue c) Bland d) Clear-liquid - ✔ ✔ D - Clear liquid Which of the following roommates would be best for the client newly admitted with gastric resection? a) A client with Crohn's disease b) A client with pneumonia c) A client with gastritis d) A client with phlebitis - ✔ ✔ D 0 A client with phlebitis Which of the following roommates would be most suitable for the client with myasthenia gravis? a) A client with hypothyroidism b) A client with Crohn's disease c) A client with pylonephritis d) A client with bronchitis - ✔ ✔ A - A client with hypothyroidism The least helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: a. Trendelenburg position b. Ice to entire extremity c. Buck's traction d. An abduction pillow - ✔ ✔ C - Buck's traction A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? a) teaching how to irrigate the illeostomy b) stopping electrolyte loss in the incisional area c) encouraging a high-fiber diet d) facilitating perineal wound drainage - ✔ ✔ D - facilitating perineal wound drainage The client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illeostomy, as in c) Myelosuppression d) Leukosytosis - ✔ ✔ B - Hypokalemia Hypokalemia is evident from the lab values listed. the other laboratory findings are within normal limits, making A, C, and D incorrect A client with cancer is to undergo an intravenous pyelogram. The nurse should: a. Force fluids 24 hours before the procedure b. Ask the client to void immediately before the study c. Hold medication that affects the central nervous system for 12 hours pre- and post-test d. Cover the client's reproductive organs with an x-ray shield - ✔ ✔ B - Ask the client to void immediately before the study A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? a. Blood pressure every 15 minutes b. Insertion of a Levine tube c. Cardiac monitoring d. Dressing changes two times per day - ✔ ✔ B - Insertion of a Levine tube A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? a. "You will be sitting for the examination procedure." b. "Portions of the procedure will cause pain or discomfort." c. "You will be given some medication to anesthetize the area." d. "You will not be able to drink fluids for 24 hours before the study." - ✔ ✔ B - "Portions of the procedure will cause pain or discomfort." A home health nurse is planning for her daily visits. Which client should the home health nurse see first? a) A client with AIDS being treated with Foscarnet b) A client with a fractured femur in a long leg cast c) A client with laryngeal cancer with a laryngetomy d) A client with diabetic ulcers to the left foot - ✔ ✔ C - A client with larynegeal cancer with a laryngetomy 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 mediastenal tube d. Percussion vibration and drainage - ✔ ✔ a - Closed check drainage The client with a lung resection will have chest tubes and a drainage collection device. He probably will not have a tracheostomy or medicastenal tube, and he will not have an order for percussion, vibration, or drainage. An infant weighs 7 pounds at birth. The expected weight by one year should be: a) 10 pounds b) 12 pounds c) 18 pounds d) 21 pounds - ✔ ✔ D - 21 pounds The birth weight of 7 pounds would indicate 21 pounds in 1 year, or triple his birth weight. 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 - ✔ ✔ A - a cephalohematoma A swelling over the right parietal area is a cephalohematoma, 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 answer 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 client is admitted to the unit after cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: a. The client is at risk for evisceration b. The client will require frequent dressing changes c. The straps provide support for drains that are inserted in the incision d. No sutures or clips are used to secure the incision - ✔ ✔ B - The client will require frequent dressing changes. The client is admitted with chronic obstructive pulmonary disease. Blood gasses reveal pH 7.36, CO2 45, O2 84, HC03 28. The nurse would assess the client to be in: a) Uncompensated acidosis b) Compensated alkalosis c) Compensated respiratory acidosis d) Uncompensated metabolic acidosis - ✔ ✔ C - Compensated respiratory acidosis b) Maintain the client's urinary output greater than 300cc per hour c) Maintain the client's body temperature of greater than 33F rectal d) Maintain the client's hematocrit less than 30% - ✔ ✔ A - Maintain the client's systolic blood pressure at 70mmHG or greater The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam? a) A gravida 4 para 3 that is Rh negative with an Rh-positive baby b) A gravida 1 para 1 that is Rh negative with an Rh-positive baby c) A gravida 2 para 0 that is Rh negative admitted after a stillbirth delivery d) A gravida 4 para 2 that is Rh negative with an Rh negative baby - ✔ ✔ D - A gravida 4 para 2 that is Rh negative with an Rh negative baby The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching? a) The graduate places the client in a supine position to read the manometer b) The graduate turns the stop-cock to the off position from the IV fluid to the client c) The graduate instructs the client to perform the Valsalva maneuver during the CVP reading d) The graduate notes the level at the top of the meniscus - ✔ ✔ C -The graduate instructs the client to perform the Valsalva maneuver during the CVP reading The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse? a) A client 2 days post-appendectomy b) A client 1 week post-thyroidectomy c) A client 3 days post-splenectomy d) A client 2 days post-thoracotomy - ✔ ✔ D - A client 2 days post-thoracotomy The nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority care? a) A 10-year-old with lacerations to the face b) A 15-year-old with sternal bruises c) A 34-year-old with a fractured femur d) A 50-year-old with dislocation of the elbow - ✔ ✔ D- A 15-year-old with sternal bruises The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: a) take the blood pressure, pulse, and temperature b) ask the client to rate his pain on a scale of 0-5 c) watch the client's facial expression d) ask the client if he is in pain - ✔ ✔ B - ask the client to rate his pain on a scale of 0-5 The nurse is assigned to care for an infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? a) Increasing the infant's fluid intake b) Maintaining the infant's body temperature at 98.6 c) Minimizing tactile stimulation d) decreasing caloric intake - ✔ ✔ A - Increasing the infant's fluid intake The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? a) bran b) fresh peaches c) cucumber salad d) yeast rolls - ✔ ✔ C - cucumber salad The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact bran cereal and fruit will help prevent constipation 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." - ✔ ✔ C- "You should use your cellphone on your right side." The client with an internal defibrillator should learn The nurse is caring for a client for removal of the pituitary gland. The nurse should be particularly of: a) Nasal Congestion b) Abdominal Tenderness 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 - ✔ ✔ D - the baby can lose up to 10% of weight due to meconium, loss of extra cellular fluid, and the initiation of breast-feeding 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 making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside? a) a pair of forceps b) a torque wrench c) a pair of wire cutters d) a screwdriver - ✔ ✔ B- a torque wrench A torque wrench is kept at the bedside table to tighten and loosen the screws of crutchfield tongs. The wrench control the amount of pressure that is placed on the screws. A pair of forceps, wire cutters, and a screwdriver would not be used. The nurse is obtaining a history of an 80-year-old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? a. "My skin is always so dry." b. "I often use a laxative for constipation." c. "I have always liked to drink a lot of ice tea." d. "I sometimes have a problem with dribbling urine." - ✔ ✔ B - "I often use a laxative for constipation." The nurse is participating in discharge teaching for the postpartal client. The nurse is aware that an effective means of managing discomfort associated with an episitomy after discharge is: a) Promethazine b) Aspirin c) Sitz bath d) Ice packs - ✔ ✔ C - Sitz bath The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? a. A weight loss of 10 pounds in 2 weeks. b. Complaints of numbness and tingling in the extremities c. A red, beefy tongue d. A hemoglobin level of 12.0gm/dL - ✔ ✔ C - A red, beefy tongue The nurse is performing discharge teaching on a client with diverticulitis who has been placed on low- roughage diet. Which food would have to be eliminated from this client's diet? a) roasted chicken b) noodles c) cooked broccoli d) custard - ✔ ✔ C - cooked broccoli The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client: a) To restrict her fat intake for 1 week before the test b) To omit creams, powders, or deodorants before the exam c) That mammography replaces the need for self-treat exams d) That mammography requires a higher dose of radiation than an x-ray. - ✔ ✔ B - to omit creams, powders, or deodorants before the exam The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? a. Hearing aid b. Contact lenses c. Wedding ring d. Artificial eye - ✔ ✔ B - Contact lenses The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instruction should be given to the patient? a) rest in bed after taking the medication for at least 30 minutes b) avoid rapid movements after taking the medication c) take the medication with water only d) allow at least one hour between taking the medication and taking other medications - ✔ ✔ C - take the medication with water only Fosamax should be taken with water only. the client should also remain upright for at least 30 minutes after taking the medication. Answers A, B, and D are not applicable to taking Fosamax. c) 1700 d)2100 - ✔ ✔ C - 1700 The physician has ordered that the client's medication be administered intrathecally. The nurse is aware that medications will be administered by which method? a. Intravenously b. Rectally c. Intramuscularly d. Into the cerebrospinal fluid - ✔ ✔ D - Into the cerebrospinal fluid The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? a) Security guard b) Registered Nurse c) Licensed Practical Nurse d) Nursing Assistant - ✔ ✔ B - Registered Nurse To ensure safety while administering a nitroglycerine patch, the nurse should: a) wear gloves b) shave the area where the patch will be applied c) wash the area thoroughly with soap and rinse with hot water d) apply the patch to the buttocks - ✔ ✔ A - Wear gloves When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? a. A history of radiation treatment in the neck region b. A history of recent orthopedic surgery c. A history of minimal physical activity d. A history of the client's food intake - ✔ ✔ A - A history of radiation treatment in the neck region Which action by the novice nurse indicates a need for further teaching? a) The nurse fails to wear gloves to remove a dressing b) The nurse applies oxygen saturation monitor to the ear lobe c) The nurse elevates the head of the bed to check the blood pressure d) The nurse paces the extremity of a dependant position to acquire a peripheral blood sample - ✔ ✔ A - The nurse fails to wear gloves to remove a dressing A 25-year-old male is brought in to the emergency room with a piece of meal in his eye. Which action by the nurse is correct? a) use a magnet to remove the object b) rinse the eye thoroughly with saline c) cover both eyes with paper cups d) patch the affected eye only - ✔ ✔ C - cover both eyes with paper cups A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? a) "Tell me about his pain." b) "What does his vomit look like?" c) "Describe his usual diet." d) "Have you noticed changes in his abdominal size?" - ✔ ✔ C - "Describe his usual diet." The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because: a) Grimacing and writhing movements decrease with relaxation and rest b) Hypoactive deep tendon reflexes become more active with rest c) Stretch reflexes are increase with rest d) Fine motor movements are improved - ✔ ✔ A - Grimacing and writhing movements decrease with relaxation and rest The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug? a) uric acid of 5 mg/dL b) hematocrit of 33% c) WBC 2,000 per cubic millimeter d) platelets 150,000 per cubic millimeter - ✔ ✔ C - 2,000 per cubic millimeter