NCLEX Practice Exam for Fundamentals of Nursing 2

1. Which intervention is an example of primary prevention?

  1. Administering digoxin (Lanoxicaps) to a patient with heart failure
  2. Administering a measles, mumps, and rubella immunization to an infant
  3. Obtaining a Papanicolaou smear to screen for cervical cancer
  4. Using occupational therapy to help a patient cope with arthritis

2. The nurse in charge is assessing a patient’s abdomen. Which examination technique should the nurse use first?

  1. Auscultation
  2. Inspection
  3. Percussion
  4. Palpation

3. Which statement regarding heart sounds is correct?

  1. S1 and S2 sound equally loud over the entire cardiac area.
  2. S1 and S2 sound fainter at the apex
  3. S1 and S2 sound fainter at the base
  4. S1 is loudest at the apex, and S2 is loudest at the base

4. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the nursing process?

  1. Assessment
  2. Nursing diagnosis
  3. Planning
  4. Evaluation

5. A female patient is receiving furosemide (Lasix), 40 mg P.O. b.i.d. in the plan of care, the nurse should emphasize teaching the patient about the importance of consuming:

  1. Fresh, green vegetables
  2. Bananas and oranges
  3. Lean red meat
  4. Creamed corn

6. The nurse in charge must monitor a patient receiving chloramphenicol for adverse drug reaction. What is the most toxic reaction to chloramphenicol?

  1. Lethal arrhythmias
  2. Malignant hypertension
  3. Status epilepticus
  4. Bone marrow suppression

7. A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

  1. Impaired gas exchanges related to increased blood flow
  2. Fluid volume excess related to peripheral vascular disease
  3. Risk for injury related to edema
  4. Altered peripheral tissue perfusion related to venous congestion

8. When positioned properly, the tip of a central venous catheter should lie in the:

  1. Superior vena cava
  2. Basilica vein
  3. Jugular vein
  4. Subclavian vein

9. Nurse Margareth is revising a client’s care plan. During which step of the nursing process does such revision take place?

  1. Assessment
  2. Planning
  3. Implementation
  4. Evaluation

10. A 65-year-old female who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, “How long will it take for my scars to disappear?” which statement would be the nurse’s best response?

  1. “The contraction phase of wound healing can take 2 to 3 years.”
  2. “Wound healing is very individual but within 4 months the scar should fade.”
  3. “With your history and the type of location of the injury, it’s hard to say.”
  4. “If you don’t develop an infection, the wound should heal any time between 1 and 3 years from now.”

11. One aspect of implementation related to drug therapy is:

  1. Developing a content outline
  2. Documenting drugs given
  3. Establishing outcome criteria
  4. Setting realistic client goals

12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor would the nurse recognize as most important?

  1. A history of increased aspirin use
  2. Recent pelvic surgery
  3. An active daily walking program
  4. A history of diabetes

13. Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance?

  1. Administer sleeping medication before bedtime
  2. Ask the client each morning to describe the quantity of sleep during the previous night
  3. Teach the client relaxation techniques, such as guided imagery, medication, and progressive muscle relaxation
  4. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks

14. While examining a client’s leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse in charge to apply?

  1. Dry sterile dressing
  2. Sterile petroleum gauze
  3. Moist, sterile saline gauze
  4. Povidone-iodine-soaked gauze

15. A male client in a behavioral-health facility receives a 30-minute psychotherapy session, and provider uses a current procedure terminology (CPT) code that bills for a 50-minute session. Under the False Claims Act, such illegal behavior is known as:

  1. Unbundling
  2. Overbilling
  3. Upcoding
  4. Misrepresentation

16. A nurse assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says that he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:

  1. Encourage the client to ask questions about personal sexuality
  2. Provide time for privacy
  3. Provide support for the spouse or significant other
  4. Suggest referral to a sex counselor or other appropriate professional

17. Using Abraham Maslow’s hierarchy of human needs, a nurse assigns highest priority to which client need?

  1. Security
  2. Elimination
  3. Safety
  4. Belonging

18. A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

  1. Inadequate vitamin D intake
  2. Inadequate protein intake
  3. Inadequate massaging of the affected area
  4. Low calcium level

19. A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

  1. Acute pain related to surgery
  2. Deficient fluid volume related to blood and fluid loss from surgery
  3. Impaired physical mobility related to surgery
  4. Risk for aspiration related to anesthesia

20. Nurse Cay inspects a client’s back and notices small hemorrhagic spots. The nurse documents that the client has:

  1. Extravasation
  2. Osteomalacia
  3. Petechiae
  4. Uremia

21. Which document addresses the client’s right to information, informed consent, and treatment refusal?

  1. Standard of Nursing Practice
  2. Patient’s Bill of Rights
  3. Nurse Practice Act
  4. Code for Nurses

22. If a blood pressure cuff is too small for a client, blood pressure readings taken with such a cuff may do which of the following?

  1. Fail to show changes in blood pressure
  2. Produce a false-high measurement
  3. Cause sciatic nerve damage
  4. Produce a false-low measurement

23. Nurse Danny has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

  1. Baked beans, hamburger, and milk
  2. Spaghetti with cream sauce, broccoli, and tea
  3. Bouillon, spinach, and soda
  4. Chicken cutlet, spinach, and soda

24. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:

  1. Assess the client’s airway
  2. Provide pain relief
  3. Encourage deep breathing and coughing
  4. Splint the chest wall with a pillow

25. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the usual reason for such a situation is:

  1. Unhappiness about the charge in leadership
  2. Unexpected feeling and emotions among the staff
  3. Fatigue from overwork and understaffing
  4. Failure to incorporate staff in decision making

26. A male client blood test results are as follows: white blood cell (WBC) count, 100ul; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 40%. Which goal would be most important for this client?

  1. Promote fluid balance
  2. Prevent infection
  3. Promote rest
  4. Prevent injury

27. Following a tonsillectomy, a female client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. Which position would be most therapeutic for this client?

  1. Semi-Fowler’s
  2. Supine
  3. High-Fowler’s
  4. Side-lying

28. Nurse Berri inspects a client’s pupil size and determines that it’s 2 mm in the left eye and 3 mm in the right eye. Unequal pupils are known as:

  1. Anisocoria
  2. Ataxia
  3. Cataract
  4. Diplopia

29. The nurse in charge is caring for an Italian client. He’s complaining of pain, but he falls asleep right after his complaint and before the nurse can assess his pain. The nurse concludes that:

  1. He may have a low threshold for pain
  2. He was faking pain
  3. Someone else gave him medication
  4. The pain went away

30. A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse’s assessment reveals jugular vein
distention. The nurse knows that when a client has jugular vein distension, it’s typically due to:

  1. A neck tumor
  2. An electrolyte imbalance
  3. Dehydration
  4. Fluid overload
Answers and Rationales
  1. Answer B. Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a smear for a screening test are examples for secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a patient cope with arthritis is an example of tertiary prevention, which aims to help a patient deal with the residual consequences of a problem or to prevent the problem from recurring.
  2. Answer B. Inspection always comes first when performing a physical examination. Percussion and palpation of the abdomen may affect bowel motility and therefore should follow auscultation.
  3. Answer D. The S1 sound—the “lub” sound—is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2 sounds. The S2—the “dub” sound—is loudest at the base. It sounds shorter, sharper, higher, and louder there than S1.
  4. Answer B. The nurse identifies human responses to actual or potential health problems during the nursing diagnosis step of the nursing process. During the assessment step, the nurse systematically collects data about the patient or family. During the planning step, the nurse develops strategies to resolve or decrease the patient’s problem. During the evaluation step, the nurse determines the effectiveness of the plan of care.
  5. Answer B. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the patient to increase intake of potassium-rich foods, such as bananas and oranges. Fresh, green vegetables; lean red meat; and creamed corn are not good sources of potassium.
  6. Answer D. The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol is not known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.
  7. Answer D. Altered peripheral tissue perfusion related to venous congestion” takes highest priority because venous inflammation and clot formation impede blood flow in a patient with deep-vein thrombosis. Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggest that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion.
  8. Answer A. When the central venous catheter is positioned correctly, its tip lies in the superior vena cava, inferior vena cava, or the right atrium—that is, in central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilica, jugular, and subclavian veins are common insertion sites for central venous catheters.
  9. Answer D. During the evaluation step of the nursing process the nurse determines whether the goals established in the care plan have been achieved, and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions.
  10. Answer C. Wound healing in a client with diabetes will be delayed. Providing the client with a time frame could give the client false information.
  11. Answer B. Although documentation isn’t a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client’s reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are part of planning rather than implementation.
  12. Answer B. The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep vein is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client’s risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease.
  13. Answer D. The nurse should begin with the simplest interventions, such as pillows or snacks, before interventions that require greater skill such as relaxation techniques. Sleep medication should be avoided whenever possible. At some point, the nurse should do a thorough sleep assessment, especially if common sense interventions fail.
  14. Answer C. Moist, sterile saline dressings support would heal and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine can irritate epithelial cells, so it shouldn’t be left on an open wound.
  15. Answer C. Upcoding is the practice of using a CPT code that’s reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren’t the terms used for this illegal practice.
  16. Answer D. The nurse should refer this client to a sex counselor or other professional. Making appropriate referrals is a valid part of planning the client’s care. The nurse doesn’t normally provide sex counseling. Therefore, providing time for privacy and providing support for the spouse or significant other are important, but not as important as referring the client to a sex counselor.
  17. Answer B. According to Maslow, elimination is a first-level or physiological need, and therefore takes priority over all other needs. Security and safety are second-level needs; belonging is a third-level need. Second- and third-level needs can be met only after a client’s first-level needs have been satisfied.
  18. Answer B. A client on bed rest suffers from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren’t factors in poor healing for this client. A pressure ulcer should never be massaged.
  19. Answer D. Risk for aspiration related to anesthesia takes priority for thins client because general anesthesia may impair the gag and swallowing reflexes, possibly leading to aspiration. The other options, although important, are secondary.
  20. Answer C. Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
  21. Answer B. The Patient’s Bill of Rights addresses the client’s right to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse’s decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
  22. Answer B. Using an undersized blood pressure cuff produces a falsely elevated blood pressure because the cuff can’t record brachial artery measurements unless it’s excessively inflated. The sciatic nerve wouldn’t be damaged by hyperinflation of the blood pressure cuff because the sciatic nerve is located in the lower extremity.
  23. Answer A. Baked beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the baked beans-hamburger-milk selection.
  24. Answer A. The first priority is to evaluate airway patency before assessing for signs of obstruction, sternal retraction, stridor, or wheezing. Airway management is always the nurse’s first priority. Pain management and splinting are important for the client’s comfort, but would come after airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.
  25. Answer B. The usual or most prevalent reason for lack of productivity in a group of competent nurses is inadequate communication or a situation in which the nurses have unexpected feeling and emotions. Although the other options could be contributing to the problematic situation, they’re less likely to be the cause.
  26. Answer B. The client is at risk for infection because WBC count is dangerously low. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.
  27. Answer D. Because of lethargy, the post tonsillectomy client is at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he awake is best. The semi-Fowler’s, supine, and high-Fowler’s position don’t allow for adequate oral drainage in a lethargic post tonsillectomy client, and increase the risk of blood aspiration.
  28. Answer A. Unequal pupils are called anisocoria. Ataxia is uncoordinated actions of involuntary muscle use. A cataract is an opacity of the eye’s lens. Diplopia is double vision.
  29. Answer A. People of Italian heritage tend to verbalize discomfort and pain. The pain was real to the client, and he may need medication when he wakes up.
  30. Answer D. Fluid overload causes the volume of blood within the vascular system to increase. This increase causes the vein to distend, which can be seen most obviously in the neck veins. A neck tumor doesn’t typically cause jugular vein distention. An electrolyte imbalance may result in fluid overload, but it doesn’t directly contribute to jugular vein distention.