NCLEX RN Registered Nurses Quiz | Practice Test 04

NCLEX RN Registered Nurses Quiz | Practice Test 04

1 >>An older adult attending a community health fair asks about receiving the necessary vaccines for the swine flu. The nurse tells the client that, to prevent the spread of swine flu, the client should receive: ?

• (A) Just the seasonal flu and the pneumonia vaccines.
• (B) The novel H1N1 vaccine instead of the seasonal vaccine.
• (C) The seasonal and novel H1N1 vaccines the same day.
• (D) The novel H1N1 and seasonal vaccines a week apart.

Solution the older adult, while less susceptible to the swine flu than younger clients, should receive both vaccines particularly if they also have pre-existing chronic conditions. The vaccines can be taken the same day.

2 >>A client, who had been playing golf in 110°F outside temperature, is admitted to an emergency department with hyperthermia. A nursing assessment would reveal: Select all that apply. ?

• (A) Absence of sweating.
• (B) Decrease in body temperature.
• (C) Increase in sweating.
• (D) Increased blood pressure.

Solution sweating decreases as heat exhaustion progresses to heat stroke.

3 >>A nurse should recognize the signs of deep vein thrombosis (DVT) if a client reports: Select all that apply. ?

• (A) Leg feeling cool with no pain.
• (B) Numbness of legs with diaphoresis.
• (C) Sudden swelling of one leg with dependent edema.
• (D) Dizziness and blurred vision.

Solution a clot in a leg vein will affect venous return and cause swelling and edema.

4 >>What nursing action is appropriate if a client has a K+ of 8 mEq/L? ?

• (A) No change is required in treatment.
• (B) Restrict intake of K+ and/or give sodium polystyrene sulfonate (Kayexalate).
• (C) Restrict fluids to reduce K+ .
• (D) Give insulin, glucose, calcium, and/or bicarbonate STAT, as ordered.

Solution this is dangerously high potassium. Glucose, insulin, and bicarbonate help move the potassium intracellularly. Calcium helps protect the heart from hyperkalemia-induced arrhythmias.

5 >>Which client has the greatest need for K+ replacement? ?

• (A) A client in renal failure with a postdialysis serum K+ of 3.4.
• (B) A client with a large NG output who is receiving Kayexalate with a serum K+ of 5.5.
• (C) A client with cardiac disease who is about to receive furosemide with a K+ of 3.5.
• (D) A client with cardiac disease who is about to receive spironolactone with a K+ of 3.5.

Solution clients with cardiac disease are vulnerable to arrhythmia when serum potassium is low. Furosemide will cause potassium loss. It is important to replace potassium before the furosemide is given.

6 >>A nurse knows that the choice of a topical antimicrobial for a client with burns is most influenced by: ?

• (A) The bactericidal and fungicidal effectiveness of the agent.
• (B) The form of the agent, whether it is a liquid or cream.
• (C) The presence and extent of eschar formation.
• (D) The ability of the agent to deliver uniform absorption.

Solution since eschar is devitalized tissue, the topical agent must be able to penetrate eschar and not be systemically toxic.

7 >>Which condition should a community health nurse report to the health department? ?

• (A) Confirmation of acid-fast bacilli.
• (B) Pruritic eruptions from Sarcoptes scabiei (scabies).
• (C) Borrelia burgdorferi (Lyme disease).
• (D) Microsporum species (ringworm) in a child who is in preschool.

Solution TB is a bacterial infectious disease that is communicable to others and is associated with significant mortality and morbidity

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8 >>Which client can be safely discharged to make room for clients suffering from a salmonella outbreak from a local food chain? ?

• (A) An 18-year-old diagnosed 1 day ago with type 1 diabetes, who lives in the college dormitory.
• (B) A 61-year-old with osteoarthritis who lives in a nursing home.
• (C) A client who is 48 hours post-MI, with a WBC of 9,000/mm3 and a CK-MB of 25 ng/mL.
• (D) A 70-year-old man with anemia and a Hct of 39% and O2 saturation of 90%.

Solution the older adult client has a chronic problem and would be supervised in the longterm care facility.

9 >>What should a nurse monitor first when caring for a client who is undergoing treatment for pheochromocytoma? ?

• (A) Pulse rate.
• (B) Blood sugar.
• (C) Blood pressure.
• (D) ECG changes

Solution treatment initially is directed at reducing the marked elevation of blood pressure quickly.

10 >>Which aspect of care is most important for a client with diabetic neuropathy? ?

• (A) Teach the client to inspect the feet using a mirror.
• (B) Teach the client to wash feet, then pat dry.
• (C) Have client moisturize feet with lotion to prevent dryness.
• (D) Teach the client to cut toenails straight across.

Solution neuropathies reduce the sensation (pain) in the client's feet. Consequently, the client is unaware of injuries or trauma to the feet that could lead to ulceration and cellulitis, which are more difficult to treat in the person who has diabetes.

11 >>A client with diabetic ketoacidosis has been treated with an insulin drip for the past 3 hours. For which imbalance is this client at greatest risk? ?

• (A) Hypovolemia.
• (B) Hypokalemia.
• (C) Hyponatremia.
• (D) Hypoglycemia.

Solution rehydration and the administration of insulin will cause the potassium to move back into the cells, resulting in a potentially even lower K+ level. Potassium replacement begins when the K+ level drops to normal to prevent hypokalemia.

12 >>Which symptom would a nurse most likely observe in a client with cholecystitis? ?

• (A) Black stools.
• (B) Nausea after a high-fat meal.
• (C) Temperature of 104°F.
• (D) Colicky left upper quadrant pain.

Solution biliary colic is common in cholecystitis and is associated with nausea and vomiting several hours after a heavy, high-fat meal.

13 >>If a client's bowel sounds are absent, a nurse should listen for at least: ?

• (A) 30 seconds.
• (B) 60 seconds.
• (C) 2 minutes.
• (D) 3 minutes.

Solution to determine if bowel sounds are absent, the nurse must listen for a minimum of 3 minutes and for as long as 5 minutes.

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14 >>What should be the first nursing action if an NG tube is not draining? ?

• (A) Irrigate the tube.
• (B) Reposition the client.
• (C) Determine tube placement.
• (D) Remove the tube and reinsert.

Solution the lack of drainage may mean the tube is no longer in the correct location.

15 >>A nurse is observing a client for possible complications of postoperative peritonitis. Which manifestations are most indicative of peritonitis? Select all that apply. ?

• (A) Hyperactive bowel sounds.
• (B) Localized or diffuse pain.
• (C) Abdominal rigidity.
• (D) Shallow respirations.

Solution Localized or diffuse pain.

16 >>A nurse would know that a client was experiencing chronic renal failure (CRF) if which signs or symptoms were present? ?

• (A) Nausea and vomiting.
• (B) Asterixis and ascites.
• (C) Kussmaul's breathing and drowsiness.
• (D) Pruritus and anemia.

Solution the irritating toxins are accumulating and result in skin irritation. Anemia results from the inadequate erythropoietin production.

17 >>A client has returned to the unit from surgery after having an arteriovenous (A-V) fistula created in the left arm. The client's teaching should include: Select all that apply. ?

• (A) Protecting site by wearing an elastic sleeve.
• (B) Squeezing a ball to increase vessel size.
• (C) Expecting fistula to be used for the next dialysis treatment.
• (D) Avoiding BP or drawing of blood samples from left arm.

Solution exercise increases the vessel size to better accommodate the large-bore needles used in hemodialysis.

18 >>After a cystectomy and construction of an ileal conduit, which complication should a nurse instruct a client to take special precautions to prevent? ?

• (A) Paralytic ileus.
• (B) Urinary calculi.
• (C) Pyelonephritis.
• (D) Mucus in the urine.

Solution an ileal conduit is a urinary diversion that allows direct access of organisms to the kidneys. Proper management of the appliance, good skin care, proper hand hygiene, and adequate fluids will reduce the chance of developing an infection.

19 >>A nurse should teach a client with a Kock pouch urinary diversion to prevent urinary tract infection by: ?

• (A) Avoiding people with upper respiratory infections (URI).
• (B) Maintaining a daily fluid intake of 2 liters.
• (C) Using sterile technique to change the appliance.
• (D) Irrigating the stoma daily.

Solution adequate fluids will maintain the urine output and optimal renal function.

20 >>A client who is scheduled for surgery to correct a retinal detachment should be positioned: ?

• (A) On the side opposite of the retinal detachment.
• (B) Upright with face down.
• (C) On the side of the retinal detachment.
• (D) Prone with face supported by pillow ring.

Solution detachments or tears are toward the back of the eye. A gas bubble is frequently used to flatten the retina (pneumatic retinopexy), and the client must be positioned to make the bubble float into position.

21 >>A client has been admitted with mild symptoms of novel H1N1. Which family member is at greatest risk for developing the infection? ?

• (A) The elderly grandmother.
• (B) A 6-year-old daughter.
• (C) The healthy 45-year-old spouse.
• (D) The 13-year-old son with asthma.

Solution the risk increases in a young person with a chronic condition. Ages 6 months to 24 years were effected more often than healthy older adults.

22 >>Which respiratory change would a nurse see most often in a client with increased intracranial pressure? ?

• (A) Nasal flaring and retractions.
• (B) Slow, irregular respirations.
• (C) Rapid, deep respirations.
• (D) Paradoxical chest movements.

Solution increased intracranial pressure (ICP) presses on the structures of the brain, causing irregularities such as Cheyne-Stokes respirations.

23 >>Leakage of spinal fluid is a potential neurosurgical complication. How should a nurse assess for this complication? ?

• (A) Check for urine specific gravity greater than 1.030.
• (B) Monitor for urine output greater than 5-10 L/day.
• (C) Test all nasal and ear drainage for glucose.
• (D) Test all spinal fluid from lumbar punctures for glucose.

Solution spinal fluid contains glucose. The RN should also look for the "halo" sign of blood drainage with a yellow ring of spinal fluid. In addition, nose and ears should be kept clean to reduce the chance of infection.

24 >>A client is admitted to an ICU with a possible brain attack (stroke). Assessment findings consistent with a brain attack include: Select all that apply. ?

• (A) Pronator drift.
• (B) Facial droop.
• (C) Slurred speech.
• (D) Weakness of affected extremity.

Solution pronator drift reflects ischemic consequences of a stroke.

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25 >>Which is the most common treatment for a client in addisonian crisis? ?

• (A) IV normal saline and glucocorticoids.
• (B) IV lactated Ringer's and packed cells.
• (C) IV 5% dextrose in normal saline and dopamine.
• (D) IV total parenteral nutrition (TPN) and insulin coverage.

Solution immediate treatment is directed toward reversing circulatory shock of addisonian crisis. Replacement of sodium and the missing steroid hormones is critical.

26 >>When a client is on chemotherapy, for which manifestations of bone marrow depression should a nurse continuously assess? ?

• (A) Night sweats and fatigue.
• (B) Loss of skin turgor and weight loss.
• (C) Low urine output and elevated BUN levels.
• (D) Ecchymosis, weakness, and fatigue.

Solution myelosuppression decreases WBCs, RBCs, and platelets. The anemia reduces oxygencarrying capacity, leading to fatigue and weakness. The reduced platelets increases bruising and bleeding tendencies.

27 >>A client is admitted to a hospital in the terminal stage of illness. At this time, a nurse, who is planning end-of-life care, should recognize that the client is most likely to fear: ?

• (A) The terminal diagnosis.
• (B) Further chemotherapy.
• (C) Being socially inadequate.
• (D) Dying alone and in pain.

Solution the client who is terminally ill most often wishes to be pain-free and to know that someone will be there in the end.

28 >>A complication of Buck's extension traction would be noted by a nurse if: ?

• (A) Redness and purulent drainage appeared at the pin site.
• (B) Toes of affected leg became dusky in color.
• (C) Skin over the fracture site was flushed.
• (D) Dorsiflexion developed in the affected foot.

Solution Buck's is skin traction to the lower leg. Circulatory disturbances and skin abrasions are the most important nursing concerns.

29 >>Due to the extent of a client's fracture, a hip prosthesis is inserted. A nurse knows that the most serious complication of implant surgery is: ?

• (A) Infection.
• (B) Phlebitis.
• (C) Urinary retention.
• (D) Narcotic addiction.

Solution there is always a risk of osteomyelitis (bone infection) with orthopedic surgery

30 >>A client returns from an operating room. The client's IV is running at 150 mL/hr; pulse is 90 and full; respirations are moist and wheezy. A nurse's initial action should be to: ?

• (A) Speed up the IV and call the physician.
• (B) Check the electrolyte levels.
• (C) Report the IV rate to the charge nurse.
• (D) Slow down the IV and call the physician.

Solution the assessment may indicate volume overload. Slowing the IV rate keeps the IV access open while waiting for further orders.

31 >>During the first 24 hours after an above-the-knee amputation for vascular disease, nursing priority for stump care would be: ?

• (A) Inspecting for redness and pressure points.
• (B) Elevating to reduce edema.
• (C) Cleansing with soap and water.
• (D) Initiating fitting for prosthesis.

Solution reducing edema will promote healing and prevent complications.

32 >>What are the emergency nursing actions for a client with a head injury due to a fall from a third-floor roof? ?

• (A) Assess respirations, assess circulation, and assess level of consciousness.
• (B) Stabilize C-spine, determine responsiveness, and begin chest compressions.
• (C) Stabilize C-spine, assess airway, and assess respirations.
• (D) Assess airway, assess respirations, and assess circulation.

Solution before assessing the CABs (compression, airway, and breathing) in this client, it is important to prevent further injury to the spinal cord.

33 >>As a nurse is assisting a client out of bed, which objective sign should indicate to the RN that the client is experiencing hypotension? ?

• (A) Pupil response is sluggish to light.
• (B) Orientation level changes.
• (C) Pulse rate increases 20 beats per minute.
• (D) Increased muscle rigidity in legs.

Solution an increase in pulse would be an attempt by the body to increase the BP.

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34 >>Which group is considered high risk for acquiring the human immunodeficiency virus (HIV)? ?

• (A) Women in menopause.
• (B) Men who are 65 plus years of age.
• (C) People who engage in oral sex.
• (D) Children of women with multiple partners.

Solution older men tend to not use condoms and do not consider themselves to be at risk for HIV.

35 >>Victims of a disastrous earthquake have been transported to an emergency department. Which victim should the nurse assess first? ?

• (A) A victim with second-degree burns on 25% of the body.
• (B) A victim with facial lacerations.
• (C) A victim with a Glasgow Coma Scale score of 15 who is hyperventilating.
• (D) A victim with no heartbeat.

Solution this client will likely survive the injury with pain medication and fluids.

36 >>A client with a tracheotomy just pulled out the tracheal tube. Which action by a RN is correct? ?

• (A) Call the respiratory therapist to reinsert the tracheal tube.
• (B) Get a hemostat to open the tracheotomy, and then try to reinsert the tube.
• (C) Give 100% O2 by mask over the stomal opening.
• (D) Place mouth to stoma and ventilate every 5 seconds.

Solution keeping the airway open is most important. Concern for contamination of the tube can be addressed after a patent airway is established.

37 >>A client with COPD is scheduled for abdominal surgery. Arterial blood gases before surgery were: pH 7.36, PCO2 54, PO2 70. After surgery the ABGs were pH 7.35, PCO2 60, PO2 65 on 2 L of O2. Which action should a nurse take? ?

• (A) Suction the client.
• (B) Have the client cough and deep breathe.
• (C) Administer sodium bicarbonate, per order.
• (D) Position the client in high Fowler's.

Solution atelectasis is likely as a result of general anesthesia. The client also appears to be hypoventilating most likely because of abdominal pain. The client should be medicated for pain before coughing and deep breathing.

38 >>Which symptom(s) would be expected if a pacemaker suddenly malfunctioned? ?

• (A) Pulse rate higher than set.
• (B) Shortness of breath, dizziness.
• (C) Atrial fibrillation, hypotension.
• (D) Premature ventricular contractions (PVCs).

Solution ventricular function would be affected, causing signs of heart failure and inadequate perfusion.

39 >>What signs will a nurse observe in a client who is experiencing right-sided heart failure? Select all that apply. ?

• (A) Bilateral ankle edema.
• (B) Jugular venous distention (JVD).
• (C) Crackles on auscultation.
• (D) Enlarged liver.

Solution the heart is unable to handle the venous return, and it will back up into the venous system, causing the ankle edema.

40 >>When assessing a client for signs of early septic shock, a nurse should observe for: ?

• (A) Cool, clammy skin.
• (B) Warm, flushed skin.
• (C) Decreased systolic blood pressure.
• (D) Disseminated intravascular coagulation (DIC).

Solution there is an increase in the body temperature, and vasodilation would occur.

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