NCLEX- RN Practice Exam 16

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1. The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

  1. Lessen the amount of cellular damage
  2. Prevent the formation of blisters
  3. Promote movement
  4. Prevent pain and discomfort

2. A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:

  1. Passing water through a dialyzing membrane
  2. Eliminating plasma proteins from the blood
  3. Lowering the pH by removing nonvolatile acids
  4. Filtering waste through a dialyzing membrane

3. During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

  1. Administer an antibiotic
  2. Contact the physician for an order for immune globulin
  3. Administer an antiviral
  4. Tell the client that he should remain in isolation for 2 weeks

4. A client hospitalized with MRSA (methicillin-resistant staph aureus) is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

  1. The client should be placed in a room with negative pressure.
  2. Infection requires close contact; therefore, the door may remain open.
  3. Transmission is highly likely, so the client should wear a mask at all times.
  4. Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

5. A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

  1. “The pain will go away in a few days.”
  2. “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”
  3. “The pain is psychological because your foot is no longer there.”
  4. “The pain and itching are due to the infection you had before the surgery.”

6. A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:

  1. Head of the pancreas
  2. Proximal third section of the small intestines
  3. Stomach and duodenum
  4. Esophagus and jejunum

7. The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

  1. Fruits
  2. Salt
  3. Pepper
  4. Ketchup

8. A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

  1. Have a Protime done monthly
  2. Eat more fruits and vegetables
  3. Drink more liquids
  4. Avoid crowds

9. The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:

  1. Perform the Valsalva maneuver as the catheter is advanced
  2. Turn his head to the left side and hyperextend the neck
  3. Take slow, deep breaths as the catheter is removed
  4. Turn his head to the right while maintaining a sniffing position

10. A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

  1. Allergies to pineapples and bananas
  2. A history of streptococcal infections
  3. Prior therapy with phenytoin
  4. A history of alcohol abuse

11. The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

  1. Using oil- or cream-based soaps
  2. Flossing between the teeth
  3. The intake of salt
  4. Using an electric razor

12. The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

  1. Apply the new tie before removing the old one.
  2. Have a helper present.
  3. Hold the tracheotomy with the nondominant hand while removing the old tie.
  4. Ask the doctor to suture the tracheostomy in place.

13. The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

  1. Turning the client to the left side
  2. Milking the tube to ensure patency
  3. Slowing the intravenous infusion
  4. Notifying the physician

14. The infant is admitted to the unit with tetrology of falot. The nurse would anticipate an order for which medication?

  1. Digoxin
  2. Epinephrine
  3. Aminophyline
  4. Atropine

15. The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.
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16. The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
  1. Tire easily
  2. Grow normally
  3. Need more calories
  4. Be more susceptible to viral infections

17. The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

  1. Determine lung maturity
  2. Measure the fetal activity
  3. Show the effect of contractions on fetal heart rate
  4. Measure the well-being of the fetus

18. The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
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  1. Instruct the client to push
  2. Perform a vaginal exam
  3. Turn off the Pitocin infusion
  4. Place the client in a semi-Fowler’s position
19. The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
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  1. Atrial flutter
  2. A sinus rhythm
  3. Ventricular tachycardia
  4. Atrial fibrillation
20. A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

  1. Be injected into the deltoid muscle
  2. Be injected into the abdomen
  3. Aspirate after the injection
  4. Clear the air from the syringe before injections

21. The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

  1. Administer the medications together in one syringe
  2. Administer the medication separately
  3. Administer the Valium, wait 5 minutes, and then inject the Phenergan
  4. Question the order because they cannot be given at the same time

22. A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

  1. Douche after intercourse
  2. Void every 3 hours
  3. Obtain a urinalysis monthly
  4. Wipe from back to front after voiding

23. Which task should be assigned to the nursing assistant?

  1. Placing the client in seclusion
  2. Emptying the Foley catheter of the preeclamptic client
  3. Feeding the client with dementia
  4. Ambulating the client with a fractured hip

24. The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

  1. A tracheotomy set
  2. A padded tongue blade
  3. An endotracheal tube
  4. An airway

25. The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

  1. Cats
  2. Dogs
  3. Turtles
  4. Birds
Answers and Rationales
  1. Answer A is correct. Rapid continuous rewarming of a frostbite primarily lessens cellular damage. It does not prevent formation of blisters. It does promote movement, but this is not the primary reason for rapid rewarming. It might increase pain for a short period of time as the feeling comes back into the extremity; therefore, answers B, C, and D are incorrect.
  2. Answer D is correct. Hemodialysis works by using a dialyzing membrane to filter waste that has accumulated in the blood. It does not pass water through a dialyzing membrane nor does it eliminate plasma proteins or lower the pH, so answers A, B, and C are incorrect.
  3. Answer B is correct. The client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus. An antibiotic or antiviral will not protect the client and it is too late to place the client in isolation, so answers A, C, and D are incorrect.
  4. Answer D is correct. The client with MRSA should be placed in isolation. Gloves, a gown, and a mask should be used when caring for the client and hand washing is very important. The door should remain closed, but a negative-pressure room is not necessary, so answers A and B are incorrect. MRSA is spread by contact with blood or body fluid or by touching the skin of the client. It is cultured from the nasal passages of the client, so the client should be instructed to cover his nose and mouth when he sneezes or coughs. It is not necessary for the client to wear the mask at all times; the nurse should wear the mask, so answer C is incorrect.
  5. Answer B is correct. Pain related to phantom limb syndrome is due to peripheral nervous system interruption. Answer A is incorrect because phantom limb pain can last several months or indefinitely. Answer C is incorrect because it is not psychological. It is also not due to infections, as stated in answer D.
  6. Answer A is correct. During a Whipple procedure the head of the pancreas, which is a part of the stomach, the jejunum, and a portion of the stomach are removed and reanastomosed. Answer B is incorrect because the proximal third of the small intestine is not removed. The entire stomach is not removed, as in answer C, and in answer D, the esophagus is not removed.
  7. Answer C is correct. Pepper is not processed and contains bacteria. Answers A, B, and D are incorrect because fruits should be cooked or washed and peeled, and salt and ketchup are allowed.
  8. Answer A is correct. Coumadin is an anticoagulant. One of the tests for bleeding time is a Protime. This test should be done monthly. Eating more fruits and vegetables is not necessary, and dark-green vegetables contain vitamin K, which increases clotting, so answer B is incorrect. Drinking more liquids and avoiding crowds is not necessary, so answers C and D are incorrect.
  9. Answer A is correct. The client who is having a central venous catheter removed should be told to hold his breath and bear down. This prevents air from entering the line. Answers B, C, and D will not facilitate removal.
  10. Answer B is correct. Clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective. There is no reason to assess the client for allergies to pineapples or bananas, there is no correlation to the use of phenytoin and streptokinase, and a history of alcohol abuse is also not a factor in the order for streptokinase; therefore, answers A, C, and D are incorrect.
  11. Answer B is correct. The client who is immune-suppressed and has bone marrow suppression should be taught not to floss his teeth because platelets are decreased. Using oils and cream-based soaps is allowed, as is eating salt and using an electric razor; therefore, answers A, C, and D are incorrect.
  12. Answer A is correct. The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. Having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. Asking the doctor to suture the tracheotomy in place is not appropriate.
  13. Answer D is correct. The output of 300mL is indicative of hemorrhage and should be reported immediately. Answer A does nothing to help the client. Milking the tube is done only with an order and will not help in this situation, and slowing the intravenous infusion is not correct; thus, answers B and C are incorrect.
  14. Answer A is correct. The infant with Tetralogy of Fallot involves four heart defects: A large ventricular septal defect (VSD), Pulmonary stenosis, Right ventricular hypertrophy and, An overriding aorta. He will be treated with digoxin to slow and strengthen the heart. Epinephrine, aminophyline, and atropine will speed the heart rate and are not used in this client; therefore, answers B, C, and D are incorrect.
  15. The correct answer is marked by an X in the diagram. The Tail of Spence is located in the upper outer quadrant of the breast.
  16. Answer A is correct. The toddler with a ventricular septal defect will tire easily. He will not grow normally but will not need more calories. He will be susceptible to bacterial infection, but he will be no more susceptible to viral infections than other children. Therefore, answers B, C, and D are incorrect.
  17. Answer B is correct. A nonstress test determines periodic movement of the fetus. It does not determine lung maturity, show contractions, or measure neurological well-being, making answers A, C, and D incorrect.
  18. Answer C is correct. The monitor indicates variable decelerations caused by cord compression. If Pitocin is infusing, the nurse should turn off the Pitocin. Instructing the client to push is incorrect because pushing could increase the decelerations and because the client is 8cm dilated, making answer A incorrect. Performing a vaginal exam should be done after turning off the Pitocin, and placing the client in a semi-Fowler’s position is not appropriate for this situation; therefore, answers B and D are incorrect.
  19. Answer C is correct. The graph indicates ventricular tachycardia. The answers in A, B, and D are not noted on the ECG strip.
  20. Answer B is correct. Lovenox injections should be given in the abdomen, not in the deltoid muscle. The client should not aspirate after the injection or clear the air from the syringe before injection. Therefore, answers A, C, and D are incorrect.
  21. Answer B is correct. Valium is not given in the same syringe with other medications, so answer A is incorrect. These medications can be given to the same client, so answer D is incorrect. In answer C, it is not necessary to wait to inject the second medication. Valium is an antianxiety medication, and Phenergan is used as an antiemetic.
  22. Answer B is correct. Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching is not recommended and obtaining a urinalysis monthly is not necessary, making answers A and C incorrect. The client should practice wiping from front to back after voiding and bowel movements, so answer D is incorrect.
  23. Answer C is correct. Of these clients, the one who should be assigned to the care of the nursing assistant is the client with dementia. Only an RN or the physician can place the client in seclusion, so answer A is incorrect. The nurse should empty the Foley catheter of the preeclamptic client because the client is unstable, making answer B incorrect. A nurse or physical therapist should ambulate the client with a fractured hip, so answer D is incorrect.
  24. Answer A is correct. The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer B is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D are incorrect.
  25. Answer D is correct. Histoplasmosis is a fungus carried by birds. It is not transmitted to humans by cats, dogs, or turtles. Therefore, answers A, B, and C are incorrect.