NCLEX-PN Practice Exam #02 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
A). Alteration in mobility.
B). Alteration in O2 perfusion.
C). Alteration in skin integrity.
D). Alteration in comfort.
Question 1 Answer: A). Alteration in mobility.
Question 1 Explanation: The client with a detached retina will have limitations in mobility before and after surgery. Alteration in comfort is incorrect because a detached retina produces no pain or discomfort. Alteration in skin integrity and alteration in O2 perfusion do not apply to the client with a detached retina; therefore, they are incorrect.
Question 2. Which instruction should be included in the discharge teaching for the client with cataract surgery?
A). It will be necessary to wear special cataract glasses..
B). The eye shield should be worn at night..
C). A prescription for medication to control post-operative pain will be needed..
D). Over-the-counter eyedrops can be used to treat redness and irritation..
Question 2 Answer: B). The eye shield should be worn at night..
Question 2 Explanation: The eye shield should be worn at night or when napping, to prevent accidental trauma to the operative eye. Prescription eyedrops, not over-the-counter eyedrops, are ordered for the client. The client might or might not require glasses following cataract surgery. Cataract surgery is pain free.
Question 3. Which of the following conditions is most likely related to the development of renal calculi?
A). Fractured femur.
B). Disc disease.
Question 3 Answer: D). Gout.
Question 3 Explanation: Gout and renal calculi are the result of increased amounts of uric acid. Pancreatitis is incorrect because it does not contribute to renal calculi.Fractured femur and disc disease can result from decreased calcium levels. Renal calculi are the result of excess calcium.
Question 4. The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
A). Rectus femoris muscle.
B). Vastus lateralis muscle.
C). Dorsogluteal muscle.
D). Deltoid muscle.
Question 4 Answer: B). Vastus lateralis muscle.
Question 4 Explanation: The nurse should administer the injection in the vastus lateralis muscle. Rectus femoris muscle and deltoid muscle are not as well developed in the newborn; therefore, they are incorrect. Answer dorsogluteal muscle is incorrect because the dorsogluteal muscle is not used for IM injections until the child is 3 years of age.
Question 5. According to Erickson’s stage of growth and development, the developmental task associated with middle childhood is:
Question 5 Answer: D). Industry.
Question 5 Explanation: According to Erikson’s Psychosocial Developmental Theory, the developmental task of middle childhood is industry versus inferiority. Trust is incorrect because it is the developmental task of infancy. Initiative is incorrect because it is the developmental task of the school-age child. Independence is incorrect because it is not one of Erikson’s developmental stages.
Question 6. A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client’s plan of care?
A). Having a staff member remain with her for 1 hour after she eats.
B). Providing the client with child-size utensils.
C). Weighing the client after she eats.
D). Placing high-protein foods in the center of the client’s plate.
Question 6 Answer: A). Having a staff member remain with her for 1 hour after she eats.
Question 6 Explanation: Having a staff member remain with the client for 1 hour after meals will help prevent self-induced vomiting. Weighing the client after she eats is incorrect because the client will weigh more after meals, which can undermine treatment. Placing high-protein foods in the center of the client’s plate is incorrect because the client will need a balanced diet and excess protein might not be well tolerated at first. Providing the client with child-size utensils is incorrect because it treats the client as a child rather than as an adult.
Question 7. The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
Question 7 Answer: D). Nausea.
Question 7 Explanation: A side effect of bronchodilators is nausea. Tinnitus and ataxia are not associated with bronchodilators; therefore, they are incorrect. Hypotension is incorrect because hypotension is a sign of toxicity, not a side effect.
Question 8. A client has returned to his room following an esophagoscopy. Before offering fluids, the nurse should give priority to assessing the client’s:
A). Movement of extremities.
B). Level of consciousness.
C). Urinary output.
D). Gag reflex.
Question 8 Answer: D). Gag reflex.
Question 8 Explanation: The client’s gag reflex is depressed before having an EGD. The nurse should give priority to checking for the return of the gag reflex before offering the client oral fluids. Level of consciousness is incorrect because conscious sedation is used. Urinary output and movement of extremities are not affected by the procedure; therefore, they are incorrect.
Question 9. A client with a bowel resection and anastamosis returns to his room with an NG tube attached to intermittent suction. Which of the following observations indicates that the nasogastric suction is working properly?
A). The client’s abdominal dressing is dry and intact..
B). The client’s abdomen is soft..
C). The client is able to swallow..
D). The client has active bowel sounds..
Question 9 Answer: B). The client’s abdomen is soft..
Question 9 Explanation: Nasogastric suction decompresses the stomach and leaves the abdomen soft and nondistended. The client is able to swallow is incorrect because it does not relate to the effectiveness of the NG suction. The client has active bowel sounds is incorrect because it relates to peristalsis, not the effectiveness of the NG suction. The client’s abdominal dressing is dry and intact is incorrect because it relates to wound healing, not the effectiveness of the NG suction.
Question 10. A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
A). Thoroughly cooking all foods.
B). Providing small, frequent meals.
C). Offering yogurt and buttermilk between meals.
D). Forcing fluids.
Question 10 Answer: B). Providing small, frequent meals.
Question 10 Explanation: Providing small, frequent meals will improve the client’s appetite and help reduce nausea. Thoroughly cooking all foods is incorrect because it does not compensate for limited absorption. Foods and beverages containing live cultures are discouraged for the immune-compromised client; therefore, offering yogurt and buttermilk incorrect. Forcing fluids is incorrect because forcing fluids will not compensate for limited absorption of the intestine.
Question 11. Which of the following symptoms is associated with exacerbation of multiple sclerosis?
Question 11 Answer: C). Diplopia.
Question 11 Explanation: The most common sign associated with exacerbation of multiple sclerosis is double vision. Other answer choices are not associated with a diagnosis of multiple sclerosis; therefore, they are incorrect.
Question 12. A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
A). Document that the infection has completely cleared.
B). Make sure that she has taken all the antibiotic.
C). Determine whether the ear infection has affected her hearing.
D). Obtain a new prescription in case the infection recurs.
Question 12 Answer: A). Document that the infection has completely cleared.
Question 12 Explanation: The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Determine whether the ear infection has affected her hearing would be done if there are repeated instances of otitis media; therefore, it is incorrect. Make sure that she has taken all the antibiotic is incorrect because it will not determine whether the child has completed the medication. Obtain a new prescription in case the infection recurs is incorrect because the purpose of the recheck is to determine whether the infection is gone.
Question 13. The treatment protocol for a client with acute lymphatic leukemia includes prednisone, methotrexate, and cimetadine. The purpose of the cimetadine is to:
A). Enhance the effectiveness of methotrexate.
B). Decrease the secretion of pancreatic enzymes.
C). Prevent a common side effect of prednisone.
D). Promote peristalsis.
Question 13 Answer: C). Prevent a common side effect of prednisone.
Question 13 Explanation: A common side effect of prednisone is gastric ulcers. Cimetadine is given to help prevent the development of ulcers. Other answer choices do not relate to the use of cimetadine; therefore, they are incorrect.
Question 14. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:
A). Respiratory rate of 20–28 per minute.
B). Cyanosis of the hands and feet.
C). The presence of conjunctival hemorrhages.
D). The mottled appearance of the trunk.
Question 14 Answer: B). Cyanosis of the hands and feet.
Question 14 Explanation: Although cyanosis of the hands and feet is common in the newborn, it accounts for an Apgar score of less than 10. The mottled appearance of the trunk suggests cooling, which is not scored by the Apgar. The presence of conjunctival hemorrhages is incorrect because conjunctival hemorrhages are not associated with the Apgar. Respiratory rate of 20–28 per minute is incorrect because it is within normal range as measured by the Apgar.
Question 15. A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
A). Tenseness of the anterior fontanel.
B). Positive Babinski reflex.
C). Negative scarf sign.
D). Periorbital edema.
Question 15 Answer: A). Tenseness of the anterior fontanel.
Question 15 Explanation: Tenseness of the anterior fontanel indicates an increase in intracranial pressure. Periorbital edema is incorrect because periorbital edema is not associated with meningitis. Positive Babinski reflex is incorrect because a positive Babinski reflex is normal in the infant. Negative scarf sign is incorrect because it relates to the preterm infant, not the infant with meningitis.
Question 16. An 8-year-old is admitted with drooling, muffled phonation, and a temperature of 102°F. The nurse should immediately notify the doctor because the child’s symptoms are suggestive of:
D). Strep throat.
Question 16 Answer: B). Epiglottitis.
Question 16 Explanation: The child’s symptoms are consistent with those of epiglottitis, an infection of the upper airway that can result in total airway obstruction. Symptoms of strep throat, laryngotracheobronchitis, and bronchiolitis are different than those presented by the client.
Question 17. The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
A). Romazicon (flumazenil).
B). Dolophine (methodone).
C). Ativan (lorazepam).
D). Antabuse (disulfiram).
Question 17 Answer: C). Ativan (lorazepam).
Question 17 Explanation: Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Antabuse (disulfiram) is incorrect because it is a medication used in aversive therapy to maintain sobriety.Romazicon (flumazenil) is incorrect because it is used for the treatment of benzodiazepine overdose. Dolophine (methodone) is incorrect because it is the treatment for opiate withdrawal.
Question 18. The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephotic syndrome. The nurse should:
A). Request a low-protein diet for the client.
B). Encourage the client to drink extra fluids.
C). Bathe the client using only mild soap and water.
D). Provide additional warmth for swollen, inflamed joints.
Question 18 Answer: B). Encourage the client to drink extra fluids.
Question 18 Explanation: The client taking Cytoxan should increase his fluid intake to prevent hemorrhagic cystitis. Other answer choices do not relate to the question; therefore, they are incorrect.
Question 19. Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
A). Apply an emollient to the baby’s skin to prevent drying.
B). Wear a gown, gloves, and a mask while caring for the infant.
C). Place the baby on enteric isolation.
D). Offer the baby sterile water between feedings of formula.
Question 19 Answer: D). Offer the baby sterile water between feedings of formula.
Question 19 Explanation: Providing additional fluids will help the newborn eliminate excess bilirubin in the stool and urine. Oils and lotions should not be used with phototherapy. Physiologic jaundice is not associated with infection; therefore, wearing a gown, gloves, and a mask and placing the baby on enteric isolation are incorrect.
Question 20. A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
A). 10 a.m..
B). 5 a.m..
C). 8 a.m..
D). 3 p.m..
Question 20 Answer: D). 3 p.m..
Question 20 Explanation: The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. 8 a.m. and 10 a.m. are incorrect because the times are too early for symptoms of hypoglycemia. 5 a.m. is incorrect because the time is too late and the client would be in severe hypoglycemia.
Question 21. A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
A). Cover both eyes and transport the client to the ER.
B). Flush the eye for 10 minutes with running water.
C). Attempt to remove the metal with a cotton-tipped applicator.
D). Cover the right eye with a sterile 4×4.
Question 21 Answer: A). Cover both eyes and transport the client to the ER.
Question 21 Explanation: The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Other answer choices are incorrect because they increase the risk of further damage to the eye.
Question 22. The primary purpose for using a CPM machine for the client with a total knee repair is to help:
A). Prevent contractures.
B). Alleviate lactic acid production in the leg muscles.
C). Decrease the pain associated with early ambulation.
D). Promote flexion of the artificial joint.
Question 22 Answer: D). Promote flexion of the artificial joint.
Question 22 Explanation: The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Other answer choices do not describe the purpose of the CPM machine; therefore, they are incorrect.
Question 23. The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
A). Flushed skin.
C). Slow pulse.
Question 23 Answer: B). Tremulousness.
Question 23 Explanation: Tremulousness is an early sign of hypoglycemia. Other answer choices are incorrect because they are symptoms of hyperglycemia.
Question 24. Which of the following meal choices is suitable for a 6-month-old infant?
A). Egg white, formula, and orange juice.
B). Rice cereal, apple juice, formula.
C). Melba toast, egg yolk, whole milk.
D). Apple juice, carrots, whole milk.
Question 24 Answer: B). Rice cereal, apple juice, formula.
Question 24 Explanation: Rice cereal, apple juice, and formula are suitable foods for the 6-month-old infant. Whole milk, orange juice, and eggs are not suitable for the young infant.
Question 25. Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
A). Pleasing others is viewed as good behavior..
B). Obeying adults is seen as correct behavior..
C). Showing respect for parents is seen as important..
D). Behavior is determined by consequences..
Question 25 Answer: D). Behavior is determined by consequences..
Question 25 Explanation: According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Other answer choices describe other stages of moral development; therefore, they are incorrect.