NCLEX Practice Exam for Physiological Adaptation In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. The nurse is caring for a 73-year-old patient with chronic pain being treated with opioids. One complication to be monitored for is:
Question 1 Answer: C). constipation.
Question 1 Explanation: Opioids slow transit through the GI tract; older patients and those being treated chronically are at increased risk. Opioids slow not speed transit through the GI tract; patients with chronic pain often lack appetite from their pain and will eat better when it is relieved; nausea, not heartburn is often seen in the upper GI tract with opioid usage.
Question 2. A client has a closed head injury. Vital signs are T 103°F rectally; pulse 100; respirations 24; B.P. 110/84. Hourly urine output is 200 ml/hr. What is the best understanding of the cause of these findings?
A). Movement of fluid from the tissue into the intravascular space, resulting from sepsis..
B). Fluid shifts from the tissue into the intravascular space due to administration of normal saline used during fluid resuscitation..
C). Damage to the hypothalamus resulting in decreased hormone production..
D). An increase in antidiuretic hormone (ADH) as a result of injury to the hypothalamus..
Question 2 Answer: C). Damage to the hypothalamus resulting in decreased hormone production..
Question 2 Explanation: Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus injury. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Normal saline is isotonic and would not cause these fluid shifts.
Question 3. The nurse is assisting a child with congestive heart failure. Which of the following would the child be least likely to manifest?
B). Weakness and fatigue..
Question 3 Answer: C). Oliguria.
Question 3 Explanation: Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure.
Question 4. An adult with chronic renal failure is receiving peritoneal dialysis. His acid-base balance and electrolyte levels are now within normal limits. His hemoglobin is 9.2 and his hematocrit is 30. The most likely cause of his anemia is:
A). eating insufficient protein due to taste changes that occur with dialysis..
B). failure of his kidneys to produce the hormone necessary to stimulate bone marrow to produce red blood cells..
C). hemolysis of red blood cells as they move past the membrane containing the dialysis solution..
D). hemodilution secondary to fluid retention..
Question 4 Answer: B). failure of his kidneys to produce the hormone necessary to stimulate bone marrow to produce red blood cells..
Question 4 Explanation: Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in hematocrit were fluid retention, one would expect to find corresponding decreases in serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce such a drop in hemoglobin. The cause of anemia in persons with chronic renal failure is lack of erythropoietin. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce red blood cells. In chronic renal failure this hormone is not produced. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside the client’s own blood vessels, so there are no mechanical forces to harm them.
Question 5. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?
A). Every 4 hours incentive spirometer.
B). Active and passive range of motion exercises twice a day.
C). Repositioning every 2 hours around the clock.
D). Chest physiotherapy twice a day.
Question 5 Answer: D). Chest physiotherapy twice a day.
Question 5 Explanation: These clients have a potential for an inability to have voluntary and involuntary muscle movement or activity. Thus, Active and passive range of motion exercises twice a day and every 4 hours incentive spirometer are inadequate with this problem in mind. Repositioning every 2 hours around the clock is not specific for prevention of complications associated with the lung.
Question 6. The RN is caring for a patient with a chest tube after a right upper lobectomy. On the day of surgery, the RN notes bubbling in the water-seal chamber. What is this, and what should the RN do?
A). air leak, expected finding.
B). air leak, notify physician.
C). suction control, expected finding.
D). suction control, decrease wall suction.
Question 6 Answer: A). air leak, expected finding.
Question 6 Explanation: Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; notifying physician would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device.
Question 7. The nurse is caring for a client with uncontrolled hypertension. Which findings require priority nursing action?
A). Lower extremity pitting edema.
B). Weakness in left arm.
C). Jugular vein distension.
Question 7 Answer: B). Weakness in left arm.
Question 7 Explanation: In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.
Question 8. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse’s priority should be:
A). Administer pain medication.
B). Initiate intravenous therapy.
C). Assess for dyspnea or stridor.
D). Cover the areas with dry sterile dressings.
Question 8 Answer: C). Assess for dyspnea or stridor.
Question 8 Explanation: Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
Question 9. The nurse is caring for a client with cirrhosis of the liver who has developed esophageal varices. The nurse understands that the best explanation for development of esophageal varices is which of the following?
A). Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities..
B). The enlarged liver displaces the esophagus toward the left, tearing the muscle layer of the esophageal blood vessels, which allows small aneurysms to form along the lower esophageal vessels..
C). Chronic low serum protein levels result in inadequate tissue repair, allowing the esophageal wall to weaken..
D). The enlarged liver presses on the diaphragm, which in turn presses on the esophageal wall, causing collapse of blood vessels into the esophageal lumen..
Question 9 Answer: A). Increased portal pressure causes some of the blood that normally circulates through the liver to be shunted to the esophageal vessels, increasing their pressure and causing varicosities..
Question 9 Explanation: While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.
Question 10. A child who is two years and six months old has had one bout of nephrosis (nephrotic syndrome). His mother suspected a recurrence when she observed swelling around his eyes. The nurse helps to confirm this condition by recognizing what additional symptom?
A). Marked proteinuria.
B). Cola-colored urine.
C). A history of positive streptococcal infection.
D). Blood pressure of 140/90..
Question 10 Answer: A). Marked proteinuria.
Question 10 Explanation: Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between 80 and 85 systolic and 50 and 60 diastolic. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls. Dark urine is not seen in nephrotic syndrome. A history of a streptococcal infection is associated with glomerulonephritis.
Question 11. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
A). Involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days..
B). Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception..
C). This procedure doesn’t impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate..
D). The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort..
Question 11 Answer: B). Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception..
Question 11 Explanation: Until the health care provider has determined that your ejaculate doesn”t contain sperm, continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control.
Question 12. The RN has finished teaching a patient about treatment of GERD. The RN knows the patient has understood the teaching if she states:
A). “I can have red wine with dinner.”.
B). “I should lie flat in bed.”.
C). “I should eat a small bedtime snack each night.”.
D). “I should eat six small meals daily.”.
Question 12 Answer: D). “I should eat six small meals daily.”.
Question 12 Explanation: Smaller more frequent meals help decrease reflux. The patient shouldn’t eat within 3 hours of bedtime; her head should be elevated-either put bed up on 6-inch blocks or use a wedge; alcohol is contraindicated-it relaxes the GE sphincter and increases reflux.
Question 13. An adult client has a comminuted fracture of the ulnar bone. He asks the nurse what type of fracture this is. The nurse’s response is based on which of these understandings?
A). The two ends of the fractured ulnar bone are pulled apart and separated from each other..
B). The ulnar bone has been crushed and broken in several places..
C). The ulnar bone has been broken in two and one end of the bone broke through the skin..
D). Only one side of the ulnar bone is broken..
Question 13 Answer: B). The ulnar bone has been crushed and broken in several places..
Question 13 Explanation: A comminuted fracture usually results from a crush injury and results in fractured and crushed bones. The bone is broken in several places. A displaced bone occurs when the two ends of the fractured bone are pulled apart and separated from each other. A compound or open fracture occurs when the bone has been broken in two and one end of the bone breaks through the skin. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick fracture happens in children whose bones are still soft.
Question 14. A child has been brought to the emergency room with an asthma attack. What signs and symptoms would the nurse expect to see?
A). A prolonged inspiratory time and a short expiratory time..
B). Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous..
C). Frequent productive coughing of clear, frothy, thin mucus progressing to thick, tenacious mucus heard only on auscultation..
D). Hypoinflation of the alveoli with resulting poor gas exchange from increasingly shallow inspirations..
Question 14 Answer: B). Swelling of the bronchial mucosa, with wheezes starting on expiration and spreading to continuous..
Question 14 Explanation: Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.
Question 15. The nurse is assessing a client admitted in ketoacidosis. The nurse can expect the client’s skin to be:
Question 15 Answer: D). flushed.
Question 15 Explanation: Cool, clammy skin is seen in hypoglycemia. Ketoacidosis causes dehydration that results in flushed, dry skin. Diaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.
Question 16. One of the most important pulmonary treatments in cystic fibrosis is:
A). chest physiotherapy.
B). oral enzymes.
C). inhaled beta agonists..
D). inhaled corticosteroids.
Question 16 Answer: A). chest physiotherapy.
Question 16 Explanation: The major pulmonary problem with CF is thick tenacious secretions. CPT moves the secretions from the small airways to the large where they can be coughed out. Inhaled beta agonists and inhaled corticosteroids are used but are secondary to chest physiotherapy; the oral enzymes that CF patients take are for digestion, not pulmonary reasons
Question 17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?
B). A heart rate between 140 to 160.
C). Pale mucosa of the eyelids and lips.
D). Hemoglobin level of 12 g/dI.
Question 17 Answer: C). Pale mucosa of the eyelids and lips.
Question 17 Explanation: In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.
Question 18. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?
A). What does the skin on the testicles look and feel like?.
B). What are you taking for pain and does it provide total relief?.
C). Did you know a consequence of epididymitis is infertility?.
D). Do you have any questions about your care?.
Question 18 Answer: A). What does the skin on the testicles look and feel like?.
Question 18 Explanation: All of the questions should be asked. However, the one about the problem is the most important to start with at this time.
Question 19. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse?
A). Participate with the compressions or breathing.
B). Go get the code cart.
C). Validate the client’s advanced directive.
D). Relieve the nurse performing CPR.
Question 19 Answer: A). Participate with the compressions or breathing.
Question 19 Explanation: Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The client’s advanced directives should have been filed on admission and choices known prior to starting CPR.
Question 20. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal
A). Split S2.
B). S3 ventricular gallop.
C). Systolic murmur.
D). Apical click.
Question 20 Answer: B). S3 ventricular gallop.
Question 20 Explanation: S3 ventricular gallop An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. Most common with congestive heart failure.