NCLEX- RN Practice Exam 10

1. The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeing really hot.” Which response would be best?

  1. “You are having an allergic reaction. I will get an order for Benadryl.”
  2. “That feeling of warmth is normal when the dye is injected.”
  3. “That feeling of warmth indicates that the clots in the coronary vessels are dissolving.”
  4.  “I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing.”

2. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

  1. The nursing assistant wears gloves while giving the client a bath.
  2.  The nurse wears goggles while drawing blood from the client.
  3.  The doctor washes his hands before examining the client.
  4. The nurse wears gloves to take the client’s vital signs.

3. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?

  1. The client loses consciousness.
  2. The client vomits.
  3. The client’s ECG indicates tachycardia.
  4. The client has a grand mal seizure.

4. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

  1. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep
  2. Scrape the skin with a piece of cardboard and bring it to the clinic
  3. Obtain a stool specimen in the afternoon
  4.  Bring a hair sample to the clinic for evaluation

5. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

  1. Treatment is not recommended for children less than 10 years of age.
  2. The entire family should be treated.
  3. Medication therapy will continue for 1 year.
  4. Intravenous antibiotic therapy will be ordered.

6. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

  1. The client receiving linear accelerator radiation therapy for lung cancer
  2. The client with a radium implant for cervical cancer
  3.  The client who has just been administered soluble brachytherapy for thyroid cancer
  4. The client who returned from placement of iridium seeds for prostate cancer

7. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

  1. The client with Cushing’s disease
  2. The client with diabetes
  3. The client with acromegaly
  4. The client with myxedema

8. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:

  1. Negligence
  2. Tort
  3. Assault
  4. Malpractice

9. Which assignment should not be performed by the licensed practical nurse?

  1. Inserting a Foley catheter
  2. Discontinuing a nasogastric tube
  3. Obtaining a sputum specimen
  4. Starting a blood transfusion

10. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

  1. Continuing to monitor the vital signs
  2. Contacting the physician
  3. Asking the client how he feels
  4. Asking the LPN to continue the post-op care

11. Which nurse should be assigned to care for the postpartal client with preeclampsia?

  1. The RN with 2 weeks of experience in postpartum
  2.  The RN with 3 years of experience in labor and delivery
  3. The RN with 10 years of experience in surgery
  4.  The RN with 1 year of experience in the neonatal intensive care unit

12. Which information should be reported to the state Board of Nursing?

  1. The facility fails to provide literature in both Spanish and English.
  2. The narcotic count has been incorrect on the unit for the past 3 days.
  3. The client fails to receive an itemized account of his bills and services received during his hospital stay.
  4. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

13. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

  1. Call the Board of Nursing
  2. File a formal reprimand
  3. Terminate the nurse
  4. Charge the nurse with a tort

14. The home health nurse is planning for the day’s visits. Which client should be seen first?

  1. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube
  2. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
  3. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
  4. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

15. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

  1. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis
  2. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
  3. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury
  4. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

16. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?

  1. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
  2.  The child should be allowed to instill his own eyedrops.
  3. The mother should be allowed to instill the eyedrops.
  4. If the eye is clear from any redness or edema, the eyedrops should be held.

17. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?

  1. “It is okay to give my child white grape juice for breakfast.”
  2. “My child can have a grilled cheese sandwich for lunch.”
  3. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
  4. “For a snack, my child can have ice cream.”

18. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

  1. Ask the parent/guardian to leave the room when assessments are being performed.
  2. Ask the parent/guardian to take the child’s favorite blanket home because anything from the outside should not be brought into the hospital.
  3. Ask the parent/guardian to room-in with the child.
  4. If the child is screaming, tell him this is inappropriate behavior.

19. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?

  1. Remove the mold and clean every week.
  2. Store the hearing aid in a warm place.
  3. Clean the lint from the hearing aid with a toothpick.
  4. Change the batteries weekly.

20. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

  1. Body image disturbance
  2. Impaired verbal communication
  3. Risk for aspiration
  4. Pain

21. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

  1. High fever
  2. Nonproductive cough
  3. Rhinitis
  4. Vomiting and diarrhea

22. The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

  1. Intravenous access supplies
  2. A tracheostomy set
  3. Intravenous fluid administration pump
  4. Supplemental oxygen

23. A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

  1. Bradycardia
  2. Decreased appetite
  3. Exophthalmos
  4. Weight gain

24. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

  1. Ham sandwich on whole-wheat toast
  2. Spaghetti and meatballs
  3. Hamburger with ketchup
  4. Cheese omelet

25. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

  1. Notify the physician
  2. Recheck the O2 saturation level in 15 minutes
  3. Apply oxygen by mask
  4. Assess the child’s pulse

26. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply.

  1. Oliguria
  2. Seizures
  3. Contractions
  4. Proteinuria 3+
  5. Muscle cramps
  6. Blood pressure 168/116 mm Hg

27. A nurse is monitoring a client with Graves’ disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.

  1. Bradycardia
  2. Fever
  3. Sweating
  4. Agitation
  5. Pallor

28. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

  1. Severely anxious client
  2. Pneumonia client
  3. Diabetic mellitus client
  4. Malnourished client
  5. Asthma client
  6. Renal failure client

29. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply.

  1. To avoid activities that require bending over
  2. To contact the surgeon if eye scratchiness occurs
  3. To place an eye shield on the surgical eye at bedtime
  4. That episodes of sudden severe pain in the eye is expected
  5. To contact the surgeon if a decrease in visual acuity occurs
  6. To take acetaminophen (Tylenol) for minor eye discomfort

30. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply.

  1. Cola is acceptable to drink on the day of the test.
  2. Tea and coffee are restricted on the day of the test.
  3. The test will take between 45 minutes and 2 hours.
  4. The hair should be washed the evening before the test.
  5. All medications need to be withheld on the day of the test.
  6. A nothing-by-mouth (NPO) status is required on the day of the test.
Answers and Rationales
  1. Answer B . It is normal for the client to have a warm sensation when dye is injected. Answers A, C, and D indicate that the nurse believes that the hot feeling is abnormal, so they are incorrect.
  2.  Answer D . It is not necessary to wear gloves to take the vital signs of the client. If the client has active infection with methicillin-resistant staphylococcus aureus, gloves should be worn. The healthcare workers in answers A, B, and C indicate knowledge of infection control by their actions.
  3. Answer D. During ECT, the client will have a grand mal seize. This indicates completion of the electroconvulsive therapy. Answers A, B, and C do not indicate that the ECT has been effective, so are incorrect.
  4. Answer A . Infection with pinworms begins when the eggs are ingested or inhaled. The eggs hatch in the upper intestine and mature in 2–8 weeks. The females then mate and migrate out the anus, where they lay up to 17,000 eggs. This causes intense itching. The mother should be told to use a flashlight to examine the rectal area about 2–3 hours after the child is asleep. Placing clear tape on a tongue blade will allow the eggs to adhere to the tape. The specimen should then be brought in to be evaluated. There is no need to scrap the skin, collect a stool specimen, or bring a sample of hair, so answers B, C, and D are incorrect.
  5. Answer B . Erterobiasis, or pinworms, is treated with Vermox (mebendazole) or Antiminth (pyrantel pamoate). The entire family should be treated to ensure that no eggs remain. Because a single treatment is usually sufficient, there is usually good compliance. The family should then be tested again in 2 weeks to ensure that no eggs remain. Answers A, C, and D are incorrect statements.
  6. Answer A . The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy. The radiation stays in the department, so the client is not radioactive. The clients in answers B, C, and D pose a risk to the pregnant nurse. These clients are radioactive in very small doses, especially upon returning from the procedures. For approximately 72 hours, the clients should dispose of urine and feces in special containers and use plastic spoons and forks.
  7. Answer A . The client with Cushing’s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. In answer B, the client with diabetes poses no risk to other clients. The client in answer C has an increase in growth hormone and poses no risk to himself or others. The client in answer D has hyperthyroidism or myxedema and poses no risk to others or himself.
  8. Answer D . The nurse could be charged with malpractice, which is failing to perform, or performing an act that causes harm to the client. Giving the infant an overdose falls into this category. Answers A, B, and C are incorrect because they apply to other wrongful acts. Negligence is failing to perform care for the client; a tort is a wrongful act committed on the client or their belongings; and assault is a violent physical or verbal attack.
  9. Answer D . The licensed practical nurse should not be assigned to begin a blood transfusion. The licensed practical nurse can insert a Foley catheter, discontinue a nasogastric tube, and collect sputum specimen; therefore, answers A, B, and C are incorrect.
  10. Answer B . The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client’s condition, making answer A incorrect. Asking the client how he feels in answer C will only provide subjective data, and the nurse in answer D is not the best nurse to assign because this client is unstable.
  11. Answer B . The nurse with 3 years of experience in labor and delivery knows the most about possible complications involving preeclampsia. The nurse in answer A is a new nurse to the unit, and the nurses in answers C and D have no experience with the postpartum client.
  12. Answer B. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to care for the client with hepatitis might result in termination, but is not of interest to the Joint Commission.
  13. Answer B . The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but these are not the first actions requested in the stem. A tort is a wrongful act to the client or his belongings and is not indicated in this instance. Therefore, Answers A, C, and D are incorrect.
  14. Answer D . The client at highest risk for complications is the client with multiple sclerosis who is being treated with cortisone via the central line. The others are more stable. MRSA is methicillin-resistant staphylococcus aureus. Vancomycin is the drug of choice and is given at scheduled times to maintain blood levels of the drug. The clients in answers A, B, and C are more stable and can be seen later.
  15. Answer B . The pregnant client and the client with a broken arm and facial lacerations are the best choices for placing in the same room. The clients in answers A, C, and D need to be placed in separate rooms due to the serious natures of their injuries.
  16. Answer A . Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child can instill the eyedrops, the area must be cleansed before administration, making answer C incorrect. Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.
  17. Answer C . Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C is correct because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration. Answers A, B, and C are incorrect because white grape juice, a grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.
  18. Answer C . The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child. Allowing the child to have items that are familiar to him is allowed and encouraged; therefore, answers A and B are incorrect. Answer D is not part of the nurse’s responsibilities.
  19. Answer B . The hearing aid should be stored in a warm, dry place. It should be cleaned daily but should not be moldy, so answer A is incorrect. A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aide, making answer C incorrect. Changing the batteries weekly, as in answer D, is not necessary.
  20. Answer C. Always remember your ABCs (airway, breathing, circulation) when selecting an answer. Although answers B and D might be appropriate for this child, answer C should have the highest priority. Answer A does not apply for a child who has undergone a tonsillectomy.
  21. Answer A . If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, making answer B incorrect. Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia, so answers C and D are incorrect.
  22. Answer B . For a child with epiglottis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside. Intravenous supplies, fluid, and oxygen will not treat an obstruction; therefore, answers A, C, and D are incorrect.
  23. Answer C. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss; therefore, answers A, B, and D are incorrect.
  24. Answer D . The child with celiac disease should be on a gluten-free diet. Answers A, B, and C all contain gluten, while answer D gives the only choice of foods that does not contain gluten.
  25. Answer C . Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.
  26. Answers: A, D, and F. Severe preeclampsia is characterized by blood pressure higher than 160/110 mm Hg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.
  27. Answers: B, C, and D. Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body’s tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
  28. Answers: C, D, and F. Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Severe anxiousness , pneumonia  and asthma are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
  29. Answers: A, C, E, and F. After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.
  30. Answers: B, C, and D. Pre-procedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.