NCLEX RN Registered Nurses Quiz | Practice Test 05
1 >>An indicator of a worsening hypovolemic shock related to GI bleeding would be: ?
(A) Decreased level of consciousness (LOC).
(B) Complaints of abdominal pain with hematemesis.
(C) Deepening, rapid respirations.
(D) Increasingly rapid, thready pulse.
2 >>A 50-year-old client is being seen in the outpatient clinic with complaints of a fever, cough, muscle soreness, and fatigue. The nurse would be concerned that the client had novel H1N1 flu if the complaints included: Select all that apply. ?
(A) Persistent cough.
(B) Shortness of breath.
(C) Persistent vomiting.
(D) Temperature of 104°F.
3 >>A client's vital signs are: BP 80/60 mm Hg, P 120, R 30, T 100.4°F. A nurse should know that these findings most likely indicate: ?
(A) Neurogenic shock from increased intracranial pressure.
(B) Hypovolemic shock from fluid volume deficits.
(C) Septic shock from gram-negative sepsis.
(D) Cardiogenic shock from MI.
4 >>A nurse should expect that a client with a severe loss of potassium (hypokalemia) from diarrhea will have: ?
5 >>Which finding should indicate to a nurse that a client has recovered from respiratory acidosis? ?
(A) Increasing respiratory rate.
(B) Increasing serum creatinine.
(C) Decreasing respiratory rate.
(D) Increasing serum bicarbonate.
6 >>The goal of care for a client with liver failure is to lower the blood ammonia level. Which actions would prevent increased ammonia? Select all that apply. ?
(A) Prevent gastrointestinal bleeding.
(B) Reduce dietary protein intake.
(C) Avoid diarrhea and vomiting.
(D) Decrease bacterial flora in the intestines.
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7 >>If a bowel obstruction occurs from inflammatory bowel disease at the transverse colon, a nurse will initially hear bowel sounds that are: ?
(A) Increased RLQ; decreased LLQ.
(B) Decreased RLQ; decreased LLQ.
(C) Absent RLQ; absent LLQ.
(D) Decreased RLQ; increased LLQ.
8 >>Identify the appropriate actions in the prevention of thrombophlebitis in a client on bedrest. Select all that apply. ?
(A) Elevate the knee gatch of the bed.
(B) Encourage exercises that dorsiflex and plantar flex the ankle.
9 >>Which nursing actions should be completed before a physician performs a thoracentesis? Select all that apply. ?
(A) Assessing the client for any allergy to local anesthetics.
(B) Teaching the client to do pursed-lip breathing during the procedure.
(C) Placing the client in an upright sitting position leaning forward, if able.
(D) Placing the client in a prone position with the affected lung on a pillow.
10 >>A nurse should evaluate the effects of coumadin, used in the treatment of deep vein thrombosis, by looking at the results of which laboratory tests? ?
(A) Prothrombin time (PT).
(B) Lee-White clotting time.
(C) Partial thromboplastin time (PTT).
(D) Fibrinogen clotting time (FCT).
11 >>Which client should be the first priority for a telephone advice RN? A client who reports: ?
(A) Headache, vomiting, and fever.
(B) Ankle swelling and shortness of breath.
(C) Productive cough.
(D) Palpitations.
12 >>To promote maximum ventilation in a client who is postoperative, a nurse should: ?
(A) Auscultate breath sounds bilaterally.
(B) Give humidified oxygen via cannula.
(C) Maintain placement of airway until the client is awake.
(D) Position the client on the side, with the neck extended.
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13 >>A nurse gets a report that a client will be admitted with an ejection fraction of 58%. Which history and physical finding should the nurse anticipate? ?
(A) Inspiratory wheezing in upper lobes, bilaterally.
(B) O2 saturation that increases from 90% to 99% when head of bed is lowered to a flat position.
(C) Crackles in the lung bases that clear with deep breathing.
(D) A client is unable to walk up two flights of stairs without dyspnea.
14 >>Management of a BUN of 71 and a creatinine of 2.7 in a client with diabetic ketoacidosis (DKA) is correctly accomplished with: ?
(A) Rehydration.
(B) Fluid restriction.
(C) Dialysis.
(D) Bladder catheterization.
15 >>A nurse notes that a client has a total bilirubin of 1.0 mg/dL. The nurse should: ?
(A) Record this normal finding.
(B) Check urine for blood.
(C) Check the stool for guaiac.
(D) Assess the sclerae for yellow coloration.
16 >>Ten hours after beginning an insulin drip on a client with diabetic ketoacidosis, the following laboratory results are returned: Na+ 130, K+ 4.4, Cl- 100, bicarb 15, BUN 60, creatinine 2.5, glucose 100. Which action should a nurse take? ?
(A) Administer potassium.
(B) Continue the insulin.
(C) Administer salt tablets.
(D) Restrict fluids.
17 >>A client is admitted with diabetic ketoacidosis (DKA). Five months ago, the hemoglobin A1c (HgbA1c) was 9.4%; currently it is 10.3%. Based on this information, a nurse should: ?
(A) Record this expected finding.
(B) Recheck the HgbA1c after the DKA is resolved.
(C) Provide diabetic teaching.
(D) Ask the physician about longer-acting insulin.
18 >>Seizure precautions should be applied to clients who have: ?
(A) A serum sodium of less than 125 mg/dL.
(B) An HgbA1c over 8%.
(C) An anion gap less than 12.
(D) Chronic peripheral neuropathies.
19 >>Which techniques are effective in communicating with a client who has complete loss of vision? Select all that apply. ?
(A) Raise the voice when talking.
(B) Avoid using the words "see" and "look."
(C) Talk very softly, since hearing is overly sensitive.
(D) Face the client when talking.
20 >>A client with mild hypertension asks a nurse for suggestions to control blood pressure. What should a nurse recommend? ?
(A) Follow a regular exercise program.
(B) Attend a stress-reduction support group.
(C) Avoid use of tobacco and limit alcohol intake.
(D) Increase intake of fruits and vegetables.
21 >>A nurse is checking a client's third cranial nerve. How should physical assessment be performed? ?
(A) Sweep a piece of cotton briskly across the cornea.
(B) Ask the client to follow the examiner's finger with the eyes.
(C) Use a Snellen chart to check visual acuity.
(D) Check pupillary reaction using a penlight.
22 >>A nurse should assess for hypercalcemia by checking a client for: ?
(A) Chvostek's sign.
(B) Trousseau's sign.
(C) Deep tendon reflex.
(D) Babinski reflex.
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23 >>The mother of a 2-year-old child is concerned her child may have novel H1N1. The nurse tells the mother that she should immediately report: ?
(A) Loss of appetite.
(B) Fever for 2 days.
(C) Vomiting
(D) Lack of alertness.
24 >>Which nursing intervention should a nurse complete first for a client experiencing addisonian crisis? ?
(A) Maintain a quiet, nonstressful environment.
(B) Take measures to avoid exertion by the client.
(C) Administer hormone replacement as prescribed.
(D) IV administration of fluid, glucose, and electrolytes.
25 >>A nurse knows that the serum sodium level of a client with a head trauma should be above 140 to: ?
(A) Keep cerebral perfusion pressure up.
(B) Prevent cerebral vasodilation.
(C) Lower the seizure threshold.
(D) Prevent cerebral edema.
26 >>A client is admitted with diabetic ketoacidosis. A nurse's first priority should be to give: ?
(A) IV bicarbonate.
(B) IV normal saline.
(C) IV albumin.
(D) Insulin subcutaneously.
27 >>A client with diabetic ketoacidosis (DKA) has been receiving IV insulin for 6 hours. Laboratory findings are: Na+ 131, K+ 3.7, Cl- 102, HCO3 22, and glucose 170. Which action should a nurse take? ?
(A) Administer 3% sodium chloride at 200 mL/hr.
(B) Expect the insulin drip to be discontinued.
(C) Give potassium IV.
(D) Administer D5 1 /4 NS with the insulin drip.
28 >>A client, who is malnourished, is admitted with a serum calcium of 7.5. A nurse should: ?
(A) Administer glucocorticoids, as ordered.
(B) Check urine for ketones.
(C) Check the serum albumin lab result.
(D) Administer Neutra-Phos, as ordered.
29 >>Following a thyroidectomy, a nurse assesses for complications related to damage or removal of the parathyroid. The nurse should assess for: ?
(A) Hypertension.
(B) Numbness around the mouth.
(C) Polyuria.
(D) Muscle weakness.
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30 >>A 19-year-old victim of trauma is admitted to an emergency department with a blood pressure of 80/50 mm Hg, and a heart rate of 130 bpm. Which action should a nurse take first? ?
(A) Give 1 liter of D5W IV as fast as possible.
(B) Give 1 liter NS IV as fast as possible.
(C) Start an additional large-bore IV as saline lock.
(D) Calculate the anion gap before selecting IV fluid.
31 >>A client with CHF has: 2+ pedal edema, jugular venous distention (JVD), bilateral basilar crackles, urine output of 1.2 L/24 hr, blood pressure of 145/88 mm Hg, Na+ of 129. A nurse should plan to: ?
(A) Restrict fluids.
(B) Give salt tablets PO.
(C) Change IV to NS.
(D) Give 3% sodium chloride IV.
32 >>A client is scheduled for outpatient bariatric surgery. Deep vein thrombosis (DVT) is best prevented by: ?
(A) Early ambulation.
(B) Postoperative low-dose heparin.
(C) Alternating compression leg wraps.
(D) Range-of-motion exercises to wrist.
33 >>Following general anesthesia for a hip replacement, an elderly client's vital signs are: P 80, R 14, blood pressure 110/78 mm Hg; O2 Sat 100% on 40% mask; pain 2/10. The client is shivering and complains of being cold. The first nursing priority should be to: ?
(A) Remove the oxygen.
(B) Check the temperature.
(C) Apply warm blankets.
(D) Give pain medication.
34 >>Which finding is consistent with a client developing fluid overload? ?
(A) Pulse over 100.
(B) Pulmonary crackles that clear with deep breathing.
(C) Concentrated urine.
(D) Oxygen saturation less than 92% on 40% O2 via facemask.
35 >>What is the best nursing action to prevent pressure sores during a long surgical procedure? ?
(A) Pad bony prominences before surgery begins.
(B) Turn the client every 2 hours.
(C) Perform range of motion on the affected joints.
(D) Provide an alternating pressure mattress.
36 >>A client with diabetes and hypertension has returned from surgery. Which nursing intervention will most likely reduce the risk of wound infection? ?
(A) Monitor blood sugar and keep it under 200 postoperatively.
(B) Place the client in contact isolation postoperatively.
(C) Administer prophylactic antibiotics 48 hours preoperatively, as ordered.
(D) Administer glucocorticoid stress hormone replacements postoperatively, as ordered.
37 >>A client asks a nurse what to expect with a condition of uncomplicated gallstones. The best response would be: ?
(A) "There may be blood in the stools, with increased mucus."
(B) "There may be RLQ cramping, with pain relieved after eating a fatty meal."
(C) "You may feel fatigue because of low hemoglobin level."
(D) "Most clients do not notice any effects."
38 >>A nurse is caring for a 32-year-old client who is 1 day post-gastric bypass. Vital signs are: T 37.9�C, P 100, R 18, BP 130/80 mm Hg, pain 2/10, O2 Sat 92% on room air. The nurse should first: ?
(A) Notify the physician for antibiotic orders.
(B) Have the client use the incentive spirometer.
(C) Increase intravenous fluids.
(D) Administer pain medication.
39 >>One day after surgery for intestinal resection, a client has no bowel sounds. Which action should a nurse take? ?
(A) Take the vital signs and notify the physician.
(B) Record this expected finding.
(C) Check rectally for impacted stool.
(D) Perform abdominal massage.
40 >>A client with gallstones asks a nurse what might have caused the condition. The nurse knows the risk of developing this condition is greater in: ?
