NCLEX- RN Practice Exam 12

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1. After the physician performs an amniotomy, the nurse’s first action should be to assess the:

  1. Degree of cervical dilation
  2. Fetal heart tones
  3. Client’s vital signs
  4. Client’s level of discomfort

2. A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?

  1. Active
  2. Latent
  3. Transition
  4. Early

3. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

  1. Teaching the mother to provide tactile stimulation
  2. Wrapping the newborn snugly in a blanket
  3. Placing the newborn in the infant seat
  4. Initiating an early infant-stimulation program

4. A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:

  1. Checking for cervical dilation
  2. Placing the client in a supine position
  3. Checking the client’s blood pressure
  4. Obtaining a fetal heart rate

5. The nurse is aware that the best way to prevent post- operative wound infection in the surgical client is to:

  1. Administer a prescribed antibiotic
  2. Wash her hands for 2 minutes before care
  3. Wear a mask when providing care
  4. Ask the client to cover her mouth when she coughs

6. The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

  1. Pain
  2. Disalignment
  3. Cool extremity
  4. Absence of pedal pulses

7. The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

  1. Lack of exercise
  2. Hormonal disturbances
  3. Lack of calcium
  4. Genetic predisposition

8. A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?

  1. The infant no longer complains of pain.
  2. The buttocks are 15° off the bed.
  3. The legs are suspended in the traction.
  4. The pins are secured within the pulley.

9. A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

  1. Utilizes a Steinman pin
  2. Requires that both legs be secured
  3. Utilizes Kirschner wires
  4. Is used primarily to heal the fractured hips

10. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

  1. Serum collection (Davol) drain
  2. Client’s pain
  3. Nutritional status
  4. Immobilizer

11. Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?

  1. “I must flush the tube with water after feedings and clamp the tube.”
  2. “I must check placement four times per day.”
  3. “I will report to the doctor any signs of indigestion.”
  4. “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”

12. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?

  1. Bleeding on the dressing is 3cm in diameter.
  2. The client has a temperature of 6°F.
  3. The client’s hematocrit is 26%.
  4. The urinary output has been 60 during the last 2 hours.

13. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

  1. The client has traveled out of the country in the last 6 months.
  2. The client’s parents are skilled stained-glass artists.
  3. The client lives in a house built in 1
  4. The client has several brothers and sisters.

14. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?

  1. High-seat commode
  2. Recliner
  3. TENS unit
  4. Abduction pillow

15. An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:

  1. Administer oxygen via nasal cannula
  2. Have narcan (naloxane) available
  3. Prepare to administer blood products
  4. Prepare to do cardioresuscitation

16. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?

  1. 16-year-old female with scoliosis
  2. 12-year-old male with a fractured femur
  3. 10-year-old male with sarcoma
  4. 6-year-old male with osteomylitis

17. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?

  1. Take the medication with milk.
  2. Report chest pain.
  3. Remain upright after taking for 30 minutes.
  4. Allow 6 weeks for optimal effects.

18. A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:

  1. Handles the cast with the fingertips
  2. Petals the cast
  3. Dries the cast with a hair dryer
  4. Allows 24 hours before bearing weight

19. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?

  1. “It will be alright for your friends to autograph the cast.”
  2. “Because the cast is made of plaster, autographing can weaken the cast.”
  3. “If they don’t use chalk to autograph, it is okay.”
  4. “Autographing or writing on the cast in any form will harm the cast.”

20. The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?

  1. Assisting the LPN with opening sterile packages and peroxide
  2. Telling the LPN that clean gloves are allowed
  3. Telling the LPN that the registered nurse should perform pin care
  4. Asking the LPN to clean the weights and pulleys with peroxide

21. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

  1. Check the bowel sounds
  2. Assess the blood pressure
  3. Offer pain medication
  4. Check for swelling

22. The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

  1. Russell’s traction
  2. Buck’s traction
  3. Halo traction
  4. Crutchfield tong traction

23. A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

  1. “Use of the CPM will permit the client to ambulate during the therapy.”
  2. “The CPM machine controls should be positioned distal to the site.”
  3.  “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”
  4. “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”

24. A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:

  1. Palms rest lightly on the handles
  2. Elbows are flexed 0°
  3. Client walks to the front of the walker
  4. Client carries the walker

25. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

  1. Attempt to replace the cord
  2. Place the client on her left side
  3. Elevate the client’s hips
  4. Cover the cord with a dry, sterile gauze

26. A nurse is told in report that a client has a positive Chvostek’s sign. What other data would the nurse expect to find on data collection? Select all that apply.

  1. Coma
  2. Tetany
  3. Diarrhea
  4. Possible seizure activity
  5. Hypoactive bowel sounds
  6. Positive Trousseau’s sign

27. A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is:

  1. Threatening to place a client in restraints
  2. Performing a surgical procedure without consent
  3. Taking photographs of the client without consent
  4. Telling the client that he or she cannot leave the hospital

28. A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

  1. Monitoring daily weight
  2. Monitoring intake and output
  3. Maintaining a low-potassium diet
  4. Monitoring extremities for edema
  5. Maintaining a low-sodium diet

29. A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?

  1. “I will give my child cough syrup if a cough develops.”
  2. “During an attack, I will take my child to a cool location.”
  3.  “I will give acetaminophen (Tylenol) if my child develops a fever.”
  4. “I will be sure that my child drinks at least three to four glasses of fluids every day.”

30. Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply.

  1. “Take the medication at bedtime.”
  2. “Take the medication with each meal.”
  3. “Take the medication on an empty stomach.”
  4.  “Side effects include abdominal bloating and flatus.”
  5. “Take some form of glucose if hypoglycemia occurs.”
  6. “Report symptoms such as shortness of breath or tiredness.”
Answers and Rationales
  1. Answer B is correct. When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort, making answers A, C, and D incorrect.
  2. Answer A is correct. The active phase of labor occurs when the client is dilated 4–7cm. The latent or early phase of labor is from 1cm to 3cm in dilation, so answers B and D are incorrect. The transition phase of labor is 8–10cm in dilation, making answer C incorrect.
  3. Answer B is correct. The infant of an addicted mother will undergo withdrawal. Snugly wrapping the infant in a blanket will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because he is irritable and needs quiet and little stimulation at this time, so answers A and D are incorrect. Placing the infant in an infant seat in answer C is incorrect because this will also cause movement that can increase muscle irritability.
  4. Answer C is correct. Following epidural anesthesia, the client should be checked for hypotension and signs of shock every 5 minutes for 15 minutes. The client can be checked for cervical dilation later after she is stable. The client should not be positioned supine because the anesthesia can move above the respiratory center and the client can stop breathing. Fetal heart tones should be assessed after the blood pressure is checked. Therefore, answers A, B, and D are incorrect.
  5. Answer B is correct. The best way to prevent post-operative wound infection is hand washing. Use of prescribed antibiotics will treat infection, not prevent infections, making answer A incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; therefore, answers C and D are incorrect.
  6. Answer B is correct. The client with a hip fracture will most likely have disalignment. Answers A, C, and D are incorrect because all fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.
  7. Answer B is correct. After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes, so answers A and C are incorrect. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis, so answer D is incorrect.
  8. Answer B is correct. The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Answer A is incorrect because this does not indicate that the traction is working correctly, nor does C. Answer D is incorrect because Bryant’s traction is a skin traction, not a skeletal traction.
  9. Answer A is correct. Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur. Answer B is incorrect because only the affected leg is in traction. Kirschner wires are used to stabilize small bones such as fingers and toes, as in answer C. Answer D is incorrect because this type of traction is not used for fractured hips.
  10. Answer A is correct. Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. The client’s pain should be assessed, but this is not life-threatening. When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used; thus, answers B, C, and D are incorrect.
  11. Answer A is correct. The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect.
  12. Answer C is correct. The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion. Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status. A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is also not uncommon and no need for concern; therefore answers A, B, and D are incorrect.
  13. Answer B is correct. Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Answer A is incorrect because simply traveling out of the country does not increase the risk. In answer C, the house was built after the lead was removed with the paint. Answer D is unrelated to the stem.
  14. Answer A is correct. The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. The recliner is good because it prevents 90° flexion but not daily activities. A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management and an abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis; therefore, answers B, C, and D are incorrect.
  15. Answer B is correct. Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula. There is no data to support the administration of blood products or cardioresuscitation, so answers A, C, and D are incorrect.
  16. Answer B is correct. The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed, the 6-year-old with osteomylitis is infected, and the client in answer A is too old and is female; therefore, answers A, C, and D are incorrect.
  17. Answer B is correct. Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors. The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect, so answers A, C, and D are incorrect.
  18. Answer D is correct. A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer A is incorrect. Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast, making answer B incorrect. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying; thus, answer C is incorrect.
  19. Answer A is correct. There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect.
  20. Answer A is correct. The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required; therefore, answers B, C, and D are incorrect.
  21. Answer A is correct. A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic illeus. Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem, so answers B, C, and D are incorrect.
  22. Answer C is correct. Halo traction will be ordered for the client with a cervical fracture. Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Cruchfield tongs are used while in the hospital and the client is immobile; therefore, answers A, B, and D are incorrect.
  23. Answer B is correct. The controller for the continuous passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. The client is in the bed during CPM therapy, so answer A is incorrect. Answer C is incorrect because clients will experience pain with the treatment. Use of the CPM does not alleviate the need for physical therapy, as suggested in answer D.
  24. Answer A is correct. The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended. Answer B is incorrect because 0° is not a relaxed angle for the elbows and will not facilitate correct walker use. The client should walk to the middle of the walker, not to the front of the walker, making answer C incorrect. The client should be taught not to carry the walker because this would not provide stability; thus, answer D is incorrect.
  25. Answer C is correct. The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed. Answers A, B, and D are incorrect. The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.
  26. Answers: B, C, D and F are correct. A positive Chvostek’s sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau’s sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval.
  27. Answer: C is correct. Invasion of privacy takes place when an individual’s private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment.
  28. Answers: A, B, D, and E are correct. The client with Cushing’s syndrome experiencing fluid overload should be maintained on a high-potassium and low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water. Monitoring weight, intake, output, and extremities for edema are all appropriate interventions for such a nursing diagnosis.
  29. Answer A is correct. Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions.
  30. Answers: B, D, E, and F are correct. The mechanism of action of acarbose is a delay in absorption of dietary carbohydrates, thereby reducing the rise in blood glucose after a meal. To accomplish this, the medication must be taken with each meal. Because of its bacterial fermentation of unabsorbed carbohydrates in the colon, side effects such as borborygmus, cramps, abdominal distention, and flatulence can occur. The medication also can affect absorption of iron, leading to symptoms (shortness of breath, tiredness) of anemia.