NCLEX RN Registered Nurses Quiz | Practice Test 03 - Multiple choice questions and Objectives

NCLEX RN Registered Nurses Quiz | Practice Test 03

1 >>A 3-year-old child is hospitalized with multiple fractures as a result of a car accident. What is the best way for a nurse to assess this child's pain level? ?

(A) Ask the child to rate pain using a numeric pain rating scale.
(B) Rely on vital sign measurements as a way to verify pain ratings.
(C) Employ the FACES pain scale with every nursing assessment.
(D) Try to have the child describe the pain's intensity and quality.

2 >>What is the priority nursing diagnosis for an infant receiving treatment for hyperbilirubinemia? ?

(A) Imbalanced body temperature.
(B) Alteration in elimination.
(C) Deficient fluid volume.
(D) Interrupted family processes.

3 >>Which assessment findings would cause a nurse to withhold scheduled immunizations in a child? Select all that apply. ?

(A) Current cold symptoms (e.g., runny nose, cough).
(B) History of recent blood transfusion.
(C) Currently taking corticosteroids.
(D) Mild diarrhea without symptoms of dehydration.

4 >>A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is prepared to care for the child when the student states: ?

(A) "I will be sure to let you know if the child's pupils become fixed and dilated."
(B) "I will keep the child straight in the supine position."
(C) "I will look for any changes in the child's respirations, pulse, or blood pressure."
(D) "I will notify the physician if the child becomes sleepy."

5 >>A child diagnosed with hypopituitarism is to begin receiving daily injections. At what time should a nurse instruct the child's parents to administer the injection each day? ?

(A) Before breakfast.
(B) At bedtime.
(C) With lunch.
(D) Any time the child prefers.

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6 >>An infant is hospitalized for congenital adrenal hyperplasia (CAH). Which medication should a nurse anticipate to be part of the child's treatment plan? ?

(A) Insulin.
(B) Cortisone.
(C) Growth hormone.
(D) Thyroid hormone.

7 >>A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the child's ear level. What should be the nurse's priority action? ?

(A) Raise the drain to the child's ear level.
(B) Leave the drain as is and monitor the CSF drainage hourly.
(C) Quickly elevate the head of the bed.
(D) Clamp the drain and complete a neurological assessment.

8 >>A nurse is planning to teach a group of 10-year-old children about drug and alcohol prevention. Which characteristics of this age group are important for the nurse to consider when developing the teaching plan? Select all that apply. ?

(A) These children are achievement-oriented.
(B) They expect good behavior to be rewarded.
(C) Their problem-solving approach tends to be concrete and systematic.
(D) The central persons in their lives tend to be friends.

9 >>A nurse visits the home of a young child to administer the Denver II developmental assessment. The child is unable to perform several required items, and the parent expresses concern regarding the child's performance. What is the best way for the nurse to respond to the parent's concerns? ?

(A) Reassure the parent that the Denver II is not a measure of the child's IQ.
(B) Offer the parent some skill-building activities and explain that the child will be reassessed in 2 weeks.
(C) Advise the parent that the child's primary physician will be notified and will make any necessary referrals.
(D) Tell the parent that it is not unusual for children to fail the Denver II.

10 >>A nurse is caring for a child with tetralogy of Fallot. Which assessment findings should the nurse expect? Select all that apply. ?

(A) Ventricular septal defect (VSD).
(B) Atrial septal defect (ASD).
(C) Overriding aorta.
(D) Pulmonic stenosis.

11 >>The parents of a child recently discharged with acute spasmodic laryngitis contact a nurse to report that the child continues to have croupy coughing spells at nighttime but is otherwise fine. What should the nurse recommend? ?

(A) Contact the child's physician for another round of antibiotics.
(B) Treat the spasms by sitting in the bathroom while a hot shower runs.
(C) Bring the child back to the emergency department as soon as possible.
(D) Elevate the child's head at bedtime using pillows.

12 >>A 12-month-old child with infantile eczema is seen at the clinic for several open lesions on the arms and legs. What should a nurse caution the child's parents against? ?

(A) Initiating a diet free of milk products.
(B) The use of topical hydrocortisone cream.
(C) Adding cornstarch to bath water.
(D) Immunization during eczema exacerbations.

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13 >>A nurse is working with a nursing student in caring for an infant who has just returned from the surgical recovery area following a cleft lip repair. Which action by the nursing student should cause the nurse to intervene? ?

(A) Placement of elbow restraints on the infant.
(B) Offering the parents a regular bottle with which to feed the infant.
(C) Positioning the infant in the semi-Fowler's position.
(D) Advising the parents of a plan to administer pain medication around the clock.

14 >>A school-age child visits a school nurse with complaints of dizziness and shaking. The nurse confirms that the child has a history of type 1 diabetes mellitus when the child becomes diaphoretic and begins to faint. What should be the nurse's first action? ?

(A) Administer an injection of glucagon.
(B) Activate EMS.
(C) Squeeze glucose gel into the cheek.
(D) Test the child's blood sugar.

15 >>A nurse should suspect Hirschsprung's disease in a child who has which type of stooling pattern? ?

(A) Pale gray stools.
(B) Currant-jelly stools.
(C) Loose, yellow stools.
(D) Thin, ribbon-like stools.

16 >>A nurse attempts to give a newborn infant the first bottle feeding. While sucking, the infant becomes cyanotic and coughs, and formula is seen coming out of the infant's nose. What should be the nurse's first action? ?

(A) Auscultate the lungs.
(B) Suction the child's airway.
(C) Obtain an order for an x-ray.
(D) Contact the physician.

17 >>A nurse is caring for a newborn infant diagnosed with hypospadias. The parents ask when the surgical repair will be complete. The nurse knows that the most likely time for completion of the surgical repair will be: ?

(A) Within the first month of life.
(B) Not until the child reaches puberty.
(C) Nearer the child's first birthday.
(D) Before the child begins school.

18 >>A clinic nurse has a follow-up appointment with an adolescent with juvenile idiopathic arthritis (JIA). What topic should be the nurse's top priority? ?

(A) Sleep patterns.
(B) Participation in daily exercise.
(C) Information regarding JIA support groups.
(D) Avoidance of alcohol use.

19 >>An RN and LVN/LPN are working as a team on a pediatric unit. Which task should the RN perform rather than delegating to the LVN/LPN? ?

(A) Obtain a 12-lead ECG on a 10-year-old.
(B) Change the dressing and examine the decubitus ulcer of a preschooler.
(C) Administer a gavage feeding to an infant with failure to thrive.
(D) Check the blood sugar of a teen in DKA.

20 >>A child is admitted with acute exacerbation of asthma. A physician orders 100% oxygen via mask. Which physician order should be a nurse's next priority? ?

(A) Continuous inhaled albuterol.
(B) IV Solu-Medrol 2 mg/kg loading dose.
(C) IV fluids at maintenance rate.
(D) Chest x-ray.

21 >>Which action by the nurse is correct for droplet precautions? ?

(A) Tests N95 respirator for fit prior to use in client room.
(B) Wears a surgical mask when within 3 feet of client.
(C) Wears eye protection upon entering the client's room.
(D) Uses sterile gloves when bathing the client.

22 >>What health teaching should be included for a client being discharged home from an emergency department with an infection? ?

(A) Take an extra antibiotic tablet as needed if the temperature is over 38.5�C.
(B) If chills occur after 24 hours, check temperature and call provider if over 38.5�C.
(C) Do not take acetaminophen for 24 hours after starting antibiotic.
(D) Use cooling measures for temperature over 37�C.

23 >>Following a head injury, a client has no cough or gag reflex. The correct nursing action for feeding this client is to: ?

(A) Position the head of bed 90 degrees for meals.
(B) Give only solid foods.
(C) Give only thick liquids.
(D) Use a feeding tube.

24 >>Which technique is correct for reducing swelling after a traumatic injury to the ankle? ?

(A) Apply intermittent ice during the first 24 hours.
(B) Apply continuous heat during the first 48 hours.
(C) Perform range of motion every 4 hours on the ankle.
(D) Position the foot below the level of the heart.

25 >>A nurse tells a client that the most effective treatment for a rash from lupus erythematosus is: ?

(A) Getting sun exposure 15 minutes each day.
(B) Washing with soap and water.
(C) Taking an antimalarial drug.
(D) Getting a varicella vaccine booster.

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26 >>Following an auto accident, a client's vital signs and hematocrit will be monitored for 24 hours for signs of internal bleeding. During this time, the client should receive: ?

(A) High-carbohydrate clear liquids orally.
(B) High-protein liquids via nasogastric tube.
(C) Intravenous total parenteral nutrition.
(D) Nothing by mouth.

27 >>Postoperatively, a client's fingers are cold and pale. Which action should a nurse take? ?

(A) Apply warm blankets.
(B) Check oxygen saturation on finger.
(C) Encourage deep breathing.
(D) Check blood sugar.

28 >>A client with cancer has anorexia and loss of weight. Which intervention should a nurse perform first? ?

(A) Giving TPN through a central line.
(B) Starting liquid nutrition through a gastric port.
(C) Starting liquid nutrition through a duodenal port.
(D) Giving megestrol and a diet of choice with nutritional supplements.

29 >>A client, who is nondiabetic and receiving 5% dextrose in one-half normal saline (D5 1 /2 NS) running at 125 mL/hr, has a blood sugar of 130 mg/dL on the morning chemistry panel. The client is concerned. It is most important for the nurse to: ?

(A) Provide diabetic teaching to the client who is newly diagnosed.
(B) Check another blood sugar and ask the physician about insulin.
(C) Explain the consequences of stress and IV fluids on blood sugar level.
(D) Keep the client NPO.

30 >>A nurse is planning care for a client admitted with chest pain after myocardial ischemia. Which outcome should the nurse document for this problem? ?

(A) Client states that pain is decreased to a tolerable level.
(B) Client agrees to rest and take pain medication.
(C) Client rates pain 0 on scale of 1 (least) to 10 (worst).
(D) Pain medication is administered within 5 minutes.

31 >>A woman who has received radiation therapy says that she feels like she is voiding through her vagina. This client may be experiencing: ?

(A) Extreme stress due to a diagnosis of cancer.
(B) Altered perineal sensations as a side effect of radiation therapy.
(C) The development of a vesicovaginal fistula.
(D) Rupture of the bladder.

32 >>The correct nursing action for a client who has a nephrostomy tube would include: ?

(A) Attaching tube to suction prn with low urine output.
(B) Changing the bandage and drainage bag daily.
(C) Irrigating, if ordered, with no more than 10 mL sterile NS.
(D) Clamping and unclamping the tube at hourly intervals.

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33 >>Following perineal surgery, a client is at risk for a wound infection related to incontinence. The correct management of this problem is to: ?

(A) Insert a continuous indwelling catheter per order.
(B) Assist to the toilet and protect the skin with cream.
(C) Limit oral fluid intake.
(D) Give a loop diuretic, such as furosemide, as ordered.

34 >>A client comes to an emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse should first ask the client if: ?

(A) There is a family history of bladder cancer.
(B) There had been recent trauma to the bladder or lower abdomen.
(C) This could be recurrence of glomerulonephritis.
(D) The client had ever had pyelonephritis.

35 >>A client with diabetes has a blood sugar of 300 mg/dL and an Na+ of 133. What nursing intervention is indicated to manage the sodium with this client? ?

(A) Pad the side rails to protect from injury during a possible seizure.
(B) Notify dietary department to send salt tablets.
(C) Encourage the client to drink water.
(D) Monitor Na+ return to normal with lowering of blood sugar.

36 >>The nursing priorities for the care of a client with acute glomerulonephritis are: Select all that apply. ?

(A) Performing range of motion.
(B) Encouraging a diet high in protein.
(C) Maintaining strict I&O.
(D) Teaching intermittent self-catheterization for urine retention.

37 >>A nurse is caring for a client with a left hemisphere stroke. The appropriate nursing actions for this client are: Select all that apply. ?

(A) Place food and the television on the left side of the bedside table.
(B) Assist the client out of bed on the right side.
(C) Raise the left side rail and place the television on the right side.
(D) Talk into the client's right ear and place food on the right side.

38 >>A nurse notes that a client, who experienced a head injury 24 hours ago has returned to the emergency department with slurred speech and is disoriented to time and place. The first nursing action should be to: ?