NCLEX-PN Practice Exam #04 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should:
A). Apply an occlusive dressing to the site.
B). Wash the skin with water and pat dry.
C). Apply a lanolin-based lotion to the skin.
D). Cover the area with a petroleum gauze.
Question 1 Answer: B). Wash the skin with water and pat dry.
Question 1 Explanation: The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore they are incorrect.
Question 2. The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client’s cancer is located in:
A). The entire pancreas.
B). The tail of the pancreas.
C). The body of the pancreas.
D). The head of the pancreas.
Question 2 Answer: D). The head of the pancreas.
Question 2 Explanation: The Whipple procedure is performed for cancer located in the head of the pancreas. Other answer choices are not correct because of the location of the cancer.
Question 3. A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:
A). Is given to determine whether the child is susceptible to pertussis.
B). Will need to be repeated when the child is 4 years of age.
C). Is a one-time injection that protects against MMR and varicella.
D). Is one of a series of injections that protects against dpt and Hib.
Question 3 Answer: D). Is one of a series of injections that protects against dpt and Hib.
Question 3 Explanation: The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenza b. A second injection is given before 4 years of age. Is given to determine whether the child is susceptible to pertussis is incorrect statement. It is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.
Question 4. The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?
A). Diet cola.
C). Potato chips.
Question 4 Answer: B). Milkshake.
Question 4 Explanation: The milkshake will provide needed calories and nutrients for the client with mania. Potato chips and diet cola are incorrect because they are high in sodium, which causes the client to excrete the lithium. Apple has some nutrient value, but not as much as the milkshake.
Question 5. The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:
A). Sits upright after eating.
B). Skips a meal.
C). Eats a meal.
D). Rests in recumbent position.
Question 5 Answer: C). Eats a meal.
Question 5 Explanation: Pain associated with duodenal ulcers is lessened if the client eats a meal or snack. Skipping a meal is incorrect because it makes the pain worse. Resting in recumbent position refers to dumping syndrome; therefore, it is incorrect. Siting upright after eating refers to gastroesophageal reflux; therefore, it is incorrect.
Question 6. A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
A). Remove the unsightly markings with acetone or alcohol.
B). Sprinkle baby powder over the radiated area.
C). Refrain from using soap or lotion on the marked area.
D). Cover the radiation site with loose gauze dressing.
Question 6 Answer: C). Refrain from using soap or lotion on the marked area.
Question 6 Explanation: The nurse should not use water, soap, or lotion on the area marked for radiation therapy. Removing the unsightly markings with acetone or alcohol is incorrect because it would remove the marking. Covering the radiation site with loose gauze dressing and Sprinkling baby powder over the radiated area are not necessary for the client receiving radiation; therefore, they are incorrect.
Question 7. A 5-month-old is diagnosed with atopic dermatitis. Nursing interventions will focus on:
A). Preventing infection.
B). Administering antipyretics.
C). Limiting oral fluid intake.
D). Keeping the skin free of moisture.
Question 7 Answer: A). Preventing infection.
Question 7 Explanation: The nurse should prevent the infant with atopic dermatitis (eczema) from scratching, which can lead to skin infections. Administering antipyretics is incorrect because fever is not associated with atopic dermatitis. Keeping the skin free of moisture and limiting oral fluid intake are incorrect because they increase dryness of the skin, which worsens the symptoms of atopic dermatitis.
Question 8. Before administering a client’s morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
A). Administer the medication and monitor the heart rate.
B). Withhold the medication and notify the doctor.
C). Withhold the medication until the heart rate increases.
D). Record the pulse rate and administer the medication.
Question 8 Answer: B). Withhold the medication and notify the doctor.
Question 8 Explanation: The medication should be withheld and the doctor should be notified. Other answer choices are incorrect because they do not provide for the client’s safety.
Question 9. The nurse is caring for a client with a history of diverticulitis. The client complains of abdominal pain, fever, and diarrhea. Which food was responsible for the client’s symptoms?
A). Whole-grain cereal.
B). Baked fish.
C). Steamed carrots.
D). Mashed potatoes.
Question 9 Answer: A). Whole-grain cereal.
Question 9 Explanation: Symptoms associated with diverticulitis are usually reported after eating popcorn, celery, raw vegetables, whole grains, and nuts. Other answer choices are incorrect because they are allowed in the diet of the client with diverticulitis.
Question 10. Which of the following meal selections is appropriate for the client with celiac disease?
A). Toast, jam, and apple juice.
B). Cheese pizza and Kool-Aid.
C). Peanut butter cookies and milk.
D). Rice Krispies bar and milk.
Question 10 Answer: D). Rice Krispies bar and milk.
Question 10 Explanation: Foods containing rice or millet are permitted on the diet of the client with celiac disease. Other answer choices are not permitted because they contain flour made from wheat, which exacerbates the symptoms of celiac disease; therefore, they are incorrect.
Question 11. A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
A). “Currant jelly” stools.
B). Palpable mass over the flank.
C). “Ribbonlike” stools.
D). Projectile vomiting.
Question 11 Answer: A). “Currant jelly” stools.
Question 11 Explanation: The child with intussusception has stools that contain blood and mucus, which are described as “currant jelly” stools. Projectile vomiting is a symptom of pyloric stenosis; therefore, it is incorrect. “Ribbonlike” stools is a symptom of Hirschsprung’s; therefore, it is incorrect. Palpable mass over the flank is a symptom of Wilms tumor; therefore, it is incorrect.
Question 12. What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
A). Solid foods should not be given until the extrusion reflex disappears, at 8–10 months of age..
B). Solid foods should be introduced one at a time, with 4- to 7-day intervals..
C). Solid foods should begin with fruits and vegetables..
D). Solid foods can be mixed in a bottle or infant feeder to make feeding easier..
Question 12 Answer: B). Solid foods should be introduced one at a time, with 4- to 7-day intervals..
Question 12 Explanation: Solid foods should be added to the diet one at a time, with 4- to 7-day intervals between new foods. The extrusion reflex fades at 3–4 months of age. Solids should not be added to the bottle and the use of infant feeders is discouraged. The first food added to the infant’s diet is rice cereal.
Question 13. A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is:
A). Brittle nails.
B). Weight gain.
C). Hair loss.
D). Sore throat.
Question 13 Answer: D). Sore throat.
Question 13 Explanation: Side effects of Pulmozyme include sore throat, hoarseness, and laryngitis. Other answer choices are not associated with Pulmozyme; therefore, they are incorrect.
Question 14. The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should:
A). Encourage the client to cough.
B). Monitor the client’s blood sugar.
C). Suction the mouth and pharynx every hour.
D). Place the client in low Trendelenburg position.
Question 14 Answer: B). Monitor the client’s blood sugar.
Question 14 Explanation: Growth hormone levels generally fall rapidly after a hypophysectomy, allowing insulin levels to rise. The result is hypoglycemia. Suctioning the mouth and pharynx every hour is incorrect because it traumatizes the oral mucosa. Placing the client in low Trendelenburg position is incorrect because the client’s head should be elevated to reduce pressure on the operative site. Encouraging the client to cough is incorrect because it increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.
Question 15. A post-operative client has an order for Demerol (meperidine) 75mg and Phenergan (promethazine) 25mg IM every 3–4 hours as needed for pain. The combination of the two medications produces a/an:
A). Antagonist effect.
B). Agonist effect.
C). Excitatory effect.
D). Synergistic effect.
Question 15 Answer: D). Synergistic effect.
Question 15 Explanation: The combination of the two medications produces an effect greater than that of either drug used alone. Agonist effects are similar to those produced by chemicals normally present in the body; therefore incorrect. Antagonist effects are those in which the actions of the drugs oppose one another; therefore incorrect. Excitatory effect is incorrect because the drugs would have a combined depressing, not excitatory, effect.
Question 16. A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to:
A). Promote healing of the oral mucosa.
B). Prevent swelling and dysphagia.
C). Decompress the stomach via suction.
D). Prevent contamination of the suture line.
Question 16 Answer: D). Prevent contamination of the suture line.
Question 16 Explanation: The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Preventing swelling and dysphagia is not a true statement; therefore, it is incorrect. Decompressing the stomach via suction is incorrect because there is no mention of suction. Promoting healing of the oral mucosa is incorrect because the oral mucosa was not involved in the laryngectomy.
Question 17. A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for:
A). Petechiae and mucosal ulcers.
B). Bleeding and pallor.
C). Fatigue and bruising.
D). Abdominal pain and anorexia.
Question 17 Answer: B). Bleeding and pallor.
Question 17 Explanation: The child with leukemia has low platelet counts, which contribute to spontaneous bleeding. Other answer choices are common in the child with leukemia, are not life-threatening.
Question 18. The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
A). Comprehending spoken words.
B). Speaking and writing.
C). Carrying out purposeful motor activity.
D). Recognizing and using an object correctly.
Question 18 Answer: B). Speaking and writing.
Question 18 Explanation: The client with expressive aphasia has trouble forming words that are understandable. Comprehending spoken words is incorrect because it describes receptive aphasia. Carrying out purposeful motor activity refers to apraxia; therefore, it is incorrect. Recognizing and using an object correctly is incorrect because it refers to agnosia.
Question 19. A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken:
A). Daily at bedtime.
B). With the first bite of a meal.
C). 1 hour before meals.
D). 30 minutes after meals.
Question 19 Answer: B). With the first bite of a meal.
Question 19 Explanation: Precose (acarbose) is to be taken with the first bite of a meal. Other answer choices are incorrect because they specify the wrong schedule for medication administration.
Question 20. A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
A). 30 minutes before sun exposure.
B). 15 minutes before sun exposure.
C). 5 minutes before sun exposure.
D). Just before sun exposure.
Question 20 Answer: A). 30 minutes before sun exposure.
Question 20 Explanation: Sunscreens of at least an SPF of 15 should be applied 20–30 minutes before going into the sun. Other answer choices are incorrect because they do not allow sufficient time for sun protection.
Question 21. The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is to:
A). Alleviate pain.
B). Prevent addiction.
C). Facilitate mobility.
D). Prevent nausea.
Question 21 Answer: A). Alleviate pain.
Question 21 Explanation: The nurse should be concerned with alleviating the client’s pain.Other answer choices are not primary objectives in the care of the client receiving an opiate analgesic; therefore, they are incorrect.
Question 22. A client with human immunodeficiency syndrome has gastrointestinal symptoms, including diarrhea. The nurse should teach the client to avoid:
A). Processed meat.
B). Raw fruits and vegetables.
C). Calcium-rich foods.
D). Canned or frozen vegetables.
Question 22 Answer: B). Raw fruits and vegetables.
Question 22 Explanation: The client with HIV should adhere to a low-bacteria diet by avoiding raw fruits and vegetables. Other answer choices are incorrect because they are permitted in the client’s diet.
Question 23. The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
A). An axillary temperature of 99°F.
B). Respiratory stridor.
C). Drooling of blood-tinged saliva.
D). Reluctance to swallow.
Question 23 Answer: B). Respiratory stridor.
Question 23 Explanation: Respiratory stridor is a symptom of partial airway obstruction. Other answer choices are expected with a tonsillectomy; therefore, they are incorrect.
Question 24. A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
A). Ordering a CBC and CPK.
B). Withholding all morning medications.
C). Transferring the client to a medical unit.
D). Administering prescribed anti-Parkinsonian medication.
Question 24 Answer: D). Administering prescribed anti-Parkinsonian medication.
Question 24 Explanation: The client’s symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome. Other answer choices are not appropriate.
Question 25. A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?
A). The client complains of blurred vision..
B). The client complains of increased thirst and increased urination..
C). The client complains of increased weight gain over the past year..
D). The client complains of ringing in the ears..
Question 25 Answer: B). The client complains of increased thirst and increased urination..
Question 25 Explanation: Increased thirst and increased urination are signs of lithium toxicity. Blurring of vision and ringing in the ears do not relate to the medication; therefore, they are incorrect. Increased weight gain is an expected side effect of the medication; therefore, it is incorrect.