NCLEX- RN Practice Exam 13

1. The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

  1. The tube will allow for equalization of the lung expansion.
  2. Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.
  3. Chest tubes relieve pain associated with a collapsed lung.
  4. Chest tubes assist with cardiac function by stabilizing lung expansion.

2. A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

  1. Mother’s educational level
  2. Infant’s birth weight
  3. Size of the mother’s breast
  4. Mother’s desire to breastfeed

3. The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

  1. The presence of scant bloody discharge
  2. Frequent urination
  3.  The presence of green-tinged amniotic fluid
  4. Moderate uterine contractions

4. The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?

  1. Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.
  2. Duration is measured by timing from the end of one contraction to the beginning of the next contraction.
  3. Duration is measured by timing from the beginning of one contraction to the end of the same contraction.
  4. Duration is measured by timing from the peak of one contraction to the end of the same contraction.

5. The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:

  1. Maternal hypoglycemia
  2. Fetal bradycardia
  3. Maternal hyperreflexia
  4. Fetal movement

6. A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?

  1. Insulin requirements moderate as the pregnancy progresses.
  2. A decreased need for insulin occurs during the second trimester.
  3. Elevations in human chorionic gonadotrophin decrease the need for insulin.
  4. Fetal development depends on adequate insulin regulation.

7. A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

  1. Providing a calm environment
  2. Obtaining a diet history
  3. Administering an analgesic
  4. Assessing fetal heart tones

8. A primigravida, age 42, is 6 weeks pregnant. Based on the client’s age, her infant is at risk for:

  1. Down syndrome
  2. Respiratory distress syndrome
  3. Turner’s syndrome
  4. Pathological jaundice

9. A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:

  1. Magnesium sulfate
  2. Calcium gluconate
  3. Dinoprostone (Prostin E.)
  4. Bromocrystine (Pardel)

10. A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:

  1. Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure
  2. Stop the infusion of magnesium sulfate and contact the physician
  3. Slow the infusion rate and turn the client on her left side
  4. Administer calcium gluconate IV push and continue to monitor the blood pressure

11. Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?

  1. An affected newborn has unaffected parents.
  2. An affected newborn has one affected parent.
  3. Affected parents have a one in four chance of passing on the defective gene.
  4. Affected parents have unaffected children who are carriers.

12. A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

  1. Because it is a state law
  2. To detect cardiovascular defects
  3. Because of her age
  4. To detect neurological defects

13. A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:

  1. There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.
  2. Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.
  3. It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.
  4. Fetal growth is arrested if thyroid medication is continued during pregnancy.

14. The nurse is responsible for performing a neonatal assessment on a full-term infant. At 1 minute, the nurse could expect to find:

  1. An apical pulse of 100
  2. An absence of tonus
  3. Cyanosis of the feet and hands
  4. Jaundice of the skin and sclera

15. A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:

  1. Supplemental oxygen
  2. Fluid restriction
  3. Blood transfusion
  4. Delivery by Caesarean section

16. A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:

  1. Increasing fluid intake
  2. Limiting ambulation
  3. Administering an enema
  4. Withholding food for 8 hours

17. An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at 1 year?

  1. 14 pounds
  2. 16 pounds
  3. 18 pounds
  4. 24 pounds

18. A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

  1. Determines the lung maturity of the fetus
  2. Measures the activity of the fetus
  3. Shows the effect of contractions on the fetal heart rate
  4. Measures the neurological well-being of the fetus

19. A full-term male has hypospadias. Which statement describes hypospadias?

  1. The urethral opening is absent.
  2. The urethra opens on the dorsal side of the penis.
  3. The penis is shorter than usual.
  4. The urethra opens on the ventral side of the penis.

20. A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

  1. Alteration in coping related to pain
  2. Potential for injury related to precipitate delivery
  3. Alteration in elimination related to anesthesia
  4. Potential for fluid volume deficit related to NPO status

21. The client with varicella will most likely have an order for which category of medication?

  1. Antibiotics
  2. Antipyretics
  3. Antivirals
  4. Anticoagulants

22. A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?

  1. Nitroglycerin
  2. Ampicillin
  3. Propranolol
  4. Verapamil

23. Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

  1.  Avoid exercise because it fatigues the joints.
  2.  Take prescribed anti-inflammatory medications with meals.
  3.  Alternate hot and cold packs to affected joints.
  4.  Avoid weight-bearing activity.

24. A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

  1. Meperidine 100mg IM q 4 hours PRN pain
  2. Mylanta 30 ccs q 4 hours via NG
  3. Cimetadine 300mg PO q.i.d.
  4. Morphine 8mg IM q 4 hours PRN pain

25. The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

  1. Hallucinogenic drugs create both stimulant and depressant effects.
  2. Hallucinogenic drugs induce a state of altered perception.
  3. Hallucinogenic drugs produce severe respiratory depression.
  4. Hallucinogenic drugs induce rapid physical dependence

26. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply.

  1. Use the fingertips to lift the cast while it is drying.
  2. Keep small toys and sharp objects away from the cast.
  3. Use a padded ruler or another padded object to scratch the skin under the cast if it itches.
  4. Place a heating pad on the lower end of the cast and over the fingers if the fingers feel cold.
  5. Contact the health care provider if the child complains of numbness or tingling in the extremity.
  6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling.

27. The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply.

  1. Diuretics
  2. Anticoagulants
  3. Anticholinergics
  4. Cardiac glycosides
  5. Phosphodiesterase (PDE) inhibitors
  6. Angiotensin-converting enzyme (ACE) inhibitors

28. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

  1. A premature infant
  2. A 101-year-old man
  3. A client on renal dialysis
  4.  A client with diabetes mellitus
  5. A 29-year-old woman with pneumonia
  6. A client with congestive heart failure

29. When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply.

  1. Increased heart rate
  2. Decline in visual acuity
  3. Decreased respiratory rate
  4. Decline in long-term memory
  5. Increased susceptibility to urinary tract infections
  6. Increased incidence of awakening after sleep onset

30. Which data indicates to the nurse that a client may be experiencing ineffective coping?

  1. Constantly neglects personal grooming
  2. Visits her husband’s grave once a month
  3. Visits the senior citizens’ center once a month
  4. Frequently looks at snapshots of her husband and family
Answers and Rationales
  1. Answer B is correct. Chest tubes work to reinflate the lung and drain serous fluid. The tube does not equalize expansion of the lungs. Pain is associated with collapse of the lung, and insertion of chest tubes is painful, so answers A and C are incorrect. Answer D is true, but this is not the primary rationale for performing chest tube insertion.
  2. Answer D is correct. Success with breastfeeding depends on many factors, but the most dependable reason for success is desire and willingness to continue the breastfeeding until the infant and mother have time to adapt. The educational level, the infant’s birth weight, and the size of the mother’s breast have nothing to do with success, so answers A, B, and C are incorrect.
  3. Answer C is correct. Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress. The presence of scant bloody discharge is normal, as are frequent urination and moderate uterine contractions, making answers A, B, and D incorrect.
  4. Answer C is correct. Duration is measured from the beginning of one contraction to the end of the same contraction. Answer A refers to frequency. Answer B is incorrect because we do not measure from the end of one contraction to the beginning of the next contraction. Duration is not measured from the peak of the contraction to the end, as stated in D.
  5. Answer B is correct. The client receiving Pitocin should be monitored for decelerations. There is no association with Pitocin use and hypoglycemia, maternal hyperreflexia, or fetal movement; therefore, answers A, C, and D are incorrect.
  6. Answer D is correct. Fetal development depends on adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters, insulin requirements do not moderate as the pregnancy progresses, and elevated human chorionic gonadotrophin elevates insulin needs, not decreases them; therefore, answers A, B, and C are incorrect.
  7. Answer A is correct. A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures. Obtaining a diet history should be done later, and administering an analgesic is not indicated because there is no data in the stem to indicate pain. Therefore, answers B and C are incorrect. Assessing the fetal heart tones is important, but this is not the highest priority in this situation as stated in answer D.
  8. Answer A is correct. The client who is age 42 is at risk for fetal anomalies such as Down syndrome and other chromosomal aberrations. Answers B, C, and D are incorrect because the client is not at higher risk for respiratory distress syndrome or pathological jaundice, and Turner’s syndrome is a genetic disorder.
  9. Answer C is correct. The client with a missed abortion will have induction of labor. Prostin E. is a form of prostaglandin used to soften the cervix. Magnesium sulfate is used for preterm labor and preeclampsia, calcium gluconate is the antidote for magnesium sulfate, and Pardel is a dopamine receptor stimulant used to treat Parkinson’s disease; therefore, answers A, B, and D are incorrect. Pardel was used at one time to dry breast milk.
  10. Answer A is correct. The client’s blood pressure and urinary output are within normal limits. The only alteration from normal is the decreased deep tendon reflexes. The nurse should continue to monitor the blood pressure and check the magnesium level. The therapeutic level is 4.8–9.6mg/dL. Answers B, C, and D are incorrect. There is no need to stop the infusion at this time or slow the rate. Calcium gluconate is the antidote for magnesium sulfate, but there is no data to indicate toxicity.
  11. Answer C is correct. Autosomal recessive disorders can be passed from the parents to the infant. If both parents pass the trait, the child will get two abnormal genes and the disease results. Parents can also pass the trait to the infant. Answer A is incorrect because, to have an affected newborn, the parents must be carriers. Answer B is incorrect because both parents must be carriers. Answer D is incorrect because the parents might have affected children.
  12. Answer D is correct. Alpha fetoprotein is a screening test done to detect neural tube defects such as spina bifida. The test is not mandatory, as stated in answer A. It does not indicate cardiovascular defects, and the mother’s age has no bearing on the need for the test, so answers B and C are incorrect.
  13. Answer B is correct. During pregnancy, the thyroid gland triples in size. This makes it more difficult to regulate thyroid medication. Answer A is incorrect because there could be a need for thyroid medication during pregnancy. Answer C is incorrect because the thyroid function does not slow. Fetal growth is not arrested if thyroid medication is continued, so answer D is incorrect.
  14. Answer C is correct. Cyanosis of the feet and hands is acrocyanosis. This is a normal finding 1 minute after birth. An apical pulse should be 120–160, and the baby should have muscle tone, making answers A and B incorrect. Jaundice immediately after birth is pathological jaundice and is abnormal, so answer D is incorrect.
  15.  Answer A is correct. Clients with sickle cell crises are treated with heat, hydration, oxygen, and pain relief. Fluids are increased, not decreased. Blood transfusions are usually not required, and the client can be delivered vaginally; thus, answers B, C, and D are incorrect.
  16. Answer A is correct. Before ultrasonography, the client should be taught to drink plenty of fluids and not void. The client may ambulate, an enema is not needed, and there is no need to withhold food for 8 hours. Therefore, answers B, C, and D are incorrect.
  17. Answer D is correct. By 1 year of age, the infant is expected to triple his birth weight. Answers A, B, and C are incorrect because they are too low.
  18. Answer B is correct. A nonstress test is done to evaluate periodic movement of the fetus. It is not done to evaluate lung maturity as in answer A. An oxytocin challenge test shows the effect of contractions on fetal heart rate and a nonstress test does not measure neurological well-being of the fetus, so answers C and D are incorrect.
  19.  Answer B is correct. Hypospadia is a condition in which there is an opening on the dorsal side of the penis. Answer A is incorrect because hypospadia does not concern the urethral opening. Answer C is incorrect because the size of the penis is not affected. Answer D is incorrect because the opening is on the dorsal side, not the ventral side.
  20. Answer A is correct. Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, making answers C and D incorrect.
  21. Answer C is correct. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants as stated in answers A and D. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone, so answer B is incorrect.
  22. Answer B is correct. Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil. There is no indication for an antibiotic such as Ampicillin, so answers A, C, and D are incorrect.
  23. Answer B is correct. Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Answers A, C, and D are incorrect. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight-bearing activities such as walking are useful but is not the best answer for the stem.
  24. Answer D is correct. Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine are ordered for pancreatitis, making answers A, B, and C incorrect.
  25. Answer B is correct. Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answers A, C, and D are incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects or produce severe respiratory depression. However, they do produce psychological dependence rather than physical dependence.
  26. Answers B, E, and F are correct. While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside of the cast because of the risk of altered skin integrity. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop.
  27. Answers A, D, E, and F are correctMedications recommended for treatment of heart failure include diuretics, cardiac glycosides such as digoxin (Lanoxin), PDE inhibitors, and ACE inhibitors. Clients in heart failure do not need anticoagulants or anticholinergics.
  28. Answers A, B, C, and F are correctClients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients
  29. Answers B, E, and F are correctAnatomical changes to the eye affect the individual’s visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client’s susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset.
  30. Answer A is correct. Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process. The remaining options identify effective coping behaviors.