NCLEX-RN Practice Exam #01

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Published on February 4, 2017 by NCLEX Exams

NCLEX-RN Practice Exam #01 In Text Mode: All questions and answers are given for reading and answering at your own pace.

Question 1. A child is 5 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the child in?
A). Initiative vs. guilt.
B). Intimacy vs. isolation.
C). Autonomy vs. shame.
D). Trust vs. mistrust.

Question 1 Answer: A). Initiative vs. guilt.
Question 1 Explanation: Initiative vs. guilt- 3-6 years old

Question 2. A new mother has some questions about (PKU). Which of the following statements made by a nurse is not correct regarding PKU?
A). The effects of PKU are reversible..
B). The urine has a high concentration of phenylpyruvic acid.
C). A Guthrie test can check the necessary lab values..
D). Mental deficits are often present with PKU..

Question 2 Answer: A). The effects of PKU are reversible..
Question 2 Explanation: The effects of PKU stay with the infant throughout their life.

Question 3. A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
A). Decreased systolic pressure.
B). Weight gain.
C). Slow pulse rate.
D). Irregular WBC lab values.

Question 3 Answer: B). Weight gain.
Question 3 Explanation: Weight gain is associated with CHF and congenital heart deficits.

Question 4. A toddler is 16 months old and has been recently admitted into the hospital. According to Erickson which of the following stages is the toddler in?
A). Intimacy vs. isolation.
B). Initiative vs. guilt.
C). Trust vs. mistrust.
D). Autonomy vs. shame.

Question 4 Answer: C). Trust vs. mistrust.
Question 4 Explanation: Trust vs. Mistrust- 12-18 months old

Question 5. A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia (select all that apply) ?
A). Increased respirations.
B). Negative urinary protein.
C). Elevated blood pressure.
D). Facial edema.

Question 5 Answer: C). Elevated blood pressure. AND D). Facial edema.
Question 5 Explanation: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

Question 6. A young adult is 20 years old and has been recently admitted into the hospital. According to Erickson which of the following stages is the adult in?
A). Autonomy vs. shame.
B). Initiative vs. guilt.
C). Intimacy vs. isolation.
D). Trust vs. mistrust.

Question 6 Answer: C). Intimacy vs. isolation.

 

Question 7. When you are taking a patient’s history, she tells you she has been depressed and is dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?
A). Elavil.
B). Pergolide.
C). Calcitonin.
D). Verapamil.

Question 7 Answer: A). Elavil.
Question 7 Explanation: Elavil is a tricyclic antidepressant.

Question 8. A mother has recently been informed that her child has Down’s syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down’s syndrome?
A). Oily skin.
B). Brachycephaly.
C). Simian crease.
D). Hypotonicity.

Question 8 Answer: A). Oily skin.
Question 8 Explanation: The skin would be dry and not oily.

Question 9. A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.
A). Notify the physician if urinary output is less than 30 ml per hour..
B). Monitor I and O’s hourly.
C). Monitor renal function and cardiac function closely.
D). Notify the physician if respirations are less than 18 per minute..
E). Keep calcium gluconate on hand in case of a magnesium sulfate overdose.
F). Monitor deep tendon reflexes hourly.
G). Monitor maternal vital signs every 2 hours.

Question 9 Answer: A). Notify the physician if urinary output is less than 30 ml per hour.. AND B). Monitor I and O’s hourly. AND C). Monitor renal function and cardiac function closely. AND E). Keep calcium gluconate on hand in case of a magnesium sulfate overdose. AND F). Monitor deep tendon reflexes hourly.
Question 9 Explanation: When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

Question 10. A 20 year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?
A). Blood cultures.
B). CT scan.
C). Arterial blood gases.
D). Blood sugar check.

Question 10 Answer: A). Blood cultures.
Question 10 Explanation: Blood cultures would be performed to investigate the fever and rash symptoms.

Question 11. A nurse if reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?
A). Streptococcus pyrogens.
B). Enterococcus faecalis.
C). Borrelia burgdorferi.
D). Bacilus anthracis.

Question 11 Answer: C). Borrelia burgdorferi.
Question 11 Explanation: Streptococcus pyrogens is linked to Rheumatic fever, Bacilus anthracis is linked to Anthrax, Enterococcus faecalis is linked to Endocarditis.

Question 12. A patient’s chart indicates a history of meningitis. Which of the following would you NOT expect to see with this patient if this condition were acute?
A). Increased appetite.
B). Fever.
C). Vomiting.
D). Poor tolerance of light.

Question 12 Answer: A). Increased appetite.
Question 12 Explanation: Loss of appetite would be expected.

Question 13. A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
A). Give the child syrup of ipecac.
B). This too shall pass.
C). Contact the Poison Control Center quickly.
D). Take the child immediately to the ER.

Question 13 Answer: C). Contact the Poison Control Center quickly.
Question 13 Explanation: The poison control center will have an exact plan of action for this child.

Question 14. Which of the following conditions would a nurse not administer erythromycin?
A). Pneumonia.
B). Multiple Sclerosis.
C). Campylobacterial infection.
D). Legionnaire’s disease.

Question 14 Answer: B). Multiple Sclerosis.
Question 14 Explanation: Erythromycin is used to treat conditions Campylobacterial infection,Legionnaire’s disease and Pneumonia

Question 15. When caring for a client with a central venous line, which of the following nursing actions should be implemented in the plan of care for chemotherapy administration?Select all that apply .
A). Administer a cytotoxic agent to keep the regimen on schedule even if blood return is not present..
B). Verify patency of the line by the presence of a blood return at regular intervals..
C). If unable to aspirate blood, reposition the client and encourage the client to cough..
D). Inspect the insertion site for swelling, erythema, or drainage..
E). Contact the health care provider about verifying placement if the status is questionable..

Question 15 Answer: B). Verify patency of the line by the presence of a blood return at regular intervals.. AND C). If unable to aspirate blood, reposition the client and encourage the client to cough.. AND D). Inspect the insertion site for swelling, erythema, or drainage.. AND E). Contact the health care provider about verifying placement if the status is questionable..
Question 15 Explanation: A major concern with intravenous administration of cytotoxic agents is vessel irritation or extravasation. The Oncology Nursing Society and hospital guidelines require frequent evaluation of blood return when administering vesicant or non vesicant chemotherapy due to the risk of extravasation. These guidelines apply to peripheral and central venous lines. In addition, central venous lines may be long-term venous access devices. Thus, difficulty drawing or aspirating blood may indicate the line is against the vessel wall or may indicate the line has occlusion. Having the client cough or move position may change the status of the line if it is temporarily against a vessel wall. Occlusion warrants more thorough evaluation via x-ray study to verify placement if the status is questionable and may require a declotting regimen.

Question 16. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?
A). Diverticulosis.
B). Irritable bowel syndrome.
C). Hypercalcaemia.
D). Hypocalcaemia.

Question 16 Answer: C). Hypercalcaemia.
Question 16 Explanation: Hypercalcaemia can cause polyuria, severe abdominal pain, and confusion.

Question 17. A patient is getting discharged from a SNF facility. The patient has a history of severe COPD and PVD. The patient is primarily concerned about their ability to breath easily. Which of the following would be the best instruction for this patient?
A). Decrease CO2 levels by increase oxygen take output during meals.
B). Cough regularly and deeply to clear airway passages..
C). Cough following bronchodilator utilization.
D). Deep breathing techniques to increase O2 levels..

Question 17 Answer: C). Cough following bronchodilator utilization.
Question 17 Explanation: The bronchodilator will allow a more productive cough.

Question 18. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following patient’s medication does not cause urine discoloration?
A). Sulfasalazine.
B). Aspirin.
C). Levodopa.
D). Phenolphthalein.

Question 18 Answer: B). Aspirin.
Question 18 Explanation: All of the others can cause urine discoloration except aspirin.

Question 19. A patient asks a nurse, “My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?”
A). Green vegetables and liver.
B). Carrots.
C). Yellow vegetables and red meat.
D). Milk.

Question 19 Answer: A). Green vegetables and liver.
Question 19 Explanation: Green vegetables and liver are a great source of folic acid.

Question 20. A nurse if reviewing a patient’s chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition?
A). Hemophilus aegyptius.
B). Yersinia pestis.
C). Helicobacter pyroli.
D). Vibrio cholera.

Question 20 Answer: A). Hemophilus aegyptius.
Question 20 Explanation: Yersinia pestis is linked to Plague, Helicobacter pyroli is linked to peptic ulcers, Vibrio cholera is linked to Cholera.

Question 21. A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC’s last in my body? The correct response is.
A). The life span of RBC is 120 days.
B). The life span of RBC is 90 days.
C). The life span of RBC is 60 days.
D). The life span of RBC is 45 days.

Question 21 Answer: A). The life span of RBC is 120 days.
Question 21 Explanation: RBC’s last for 120 days in the body

Question 22. A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply:
A). Chronic depression.
B). Excessive caffeine.
C). Chronic stress.
D). Generalized pain.
E). Severe anxiety.
F). Environmental noise.

Question 22 Answer: B). Excessive caffeine. AND C). Chronic stress. AND F). Environmental noise.
Question 22 Explanation: Acute or primary insomnia is caused by emotional or physical discomfort not caused by the direct physiologic effects of a substance or a medical condition. Excessive caffeine intake is an example of disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and/or emotional and therefore is related to primary insomnia.

Question 23. A fifty-year-old blind and deaf patient has been admitted to your floor. As the charge nurse your primary responsibility for this patient is?
A). Communicate with your supervisor your patient safety concerns..
B). Provide a secure environment for the patient..
C). Continuously update the patient on the social environment..
D). Let others know about the patient’s deficits..

Question 23 Answer: B). Provide a secure environment for the patient..
Question 23 Explanation: This patient’s safety is your primary concern.

Question 24. A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal?
A). 6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg.
B). 11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg.
C). 5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg.
D). 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg.

Question 24 Answer: D). 13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg.
Question 24 Explanation: HR and Respirations are slightly increased. BP is down.

Question 25. A nurse is putting together a presentation on meningitis. Which of the following microorganisms has NOT been linked to meningitis in humans?
A). H. influenza.
B). N. meningitis.
C). Cl. difficile.
D). S. pneumonia.

Question 25 Answer: C). Cl. difficile.
Question 25 Explanation: Cl. difficile has not been linked to meningitis

Question 26. The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply):
A). Fowler’s.
B). Prone.
C). Supine.
D). Side-lying.

Question 26 Answer: C). Supine. AND D). Side-lying.
Question 26 Explanation: Research demonstrate that the occurrence of SIDS is reduced with these two positions.

Question 27. When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.
A). Has duration of normally 0.11 seconds or less..
B). Reflects atrial muscle depolarization.
C). Indicated electrical impulse beginning at the AV node.
D). Reflects electrical impulse beginning at the SA node.
E). Identifies ventricular muscle depolarization.

Question 27 Answer: A). Has duration of normally 0.11 seconds or less.. AND B). Reflects atrial muscle depolarization. AND D). Reflects electrical impulse beginning at the SA node.
Question 27 Explanation: In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

Question 28. You are responsible for reviewing the nursing unit’s refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator’s contents?
A). Epogen (injection).
B). Corgard.
C). Humulin (injection).
D). Urokinase.

Question 28 Answer: B). Corgard.
Question 28 Explanation: Corgard could be removed from the refigerator.

Question 29. A patient’s chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?
A). Weight gain.
B). Vomiting.
C). Acetone breath smell.
D). Extreme Thirst.

Question 29 Answer: A). Weight gain.
Question 29 Explanation: Weight loss would be expected.

Question 30. Select all that apply to the use of barbiturates in treating insomnia:
A). When the barbiturates are discontinued, the REM sleep increases..
B). Nightmares are often an adverse effect when discontinuing barbiturates..
C). Barbiturates deprive people of NREM sleep.
D). Barbiturates deprive people of REM sleep.
E). When the barbiturates are discontinued, the NREM sleep increases..

Question 30 Answer: A). When the barbiturates are discontinued, the REM sleep increases.. AND B). Nightmares are often an adverse effect when discontinuing barbiturates.. AND D). Barbiturates deprive people of REM sleep.
Question 30 Explanation: Barbiturates deprive people of REM sleep. When the barbiturate is stopped and REM sleep once again occurs, a rebound phenomenon occurs. During this phenomenon, the persons dream time constitutes a larger percentage of the total sleep pattern, and the dreams are often nightmares.

Question 31. A nurse is reviewing a patient’s medication during shift change. Which of the following medication would be contraindicated if the patient were pregnant? Note: More than one answer may be correct.
A). Catapress.
B). Celebrex.
C). Coumadin.
D). Finasteride.
E). Clofazimine.
F). Habitrol.

Question 31 Answer: C). Coumadin. AND D). Finasteride.
Question 31 Explanation: Coumadin and Finasteride are both contraindicated with pregnancy.

Question 32. A nurse is reviewing a patient’s PMH. The history indicates photosensitive reactions to medications. Which of the following drugs has not been associated with photosensitive reactions? Note: More than one answer may be correct.
A). Bactrim.
B). Accutane.
C). Cipro.
D). Nitrodur.
E). Sulfonamide.
F). Noroxin.

Question 32 Answer: D). Nitrodur.
Question 32 Explanation: All of the others have can cause photosensitivity reactions except Nitrodur.

Question 33. A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient?
A). Within 48 hours of discharge.
B). Upon admit.
C). Preoperative discussion.
D). Following surgery.

Question 33 Answer: B). Upon admit.
Question 33 Explanation: Discharge education begins upon admit.

Question 34. Select all that apply that is appropriate when there is a benzodiazepine overdose:
A). Administration of Flumazenil.
B). Administration of syrup of ipecac.
C). Hemodialysis.
D). Gastric lavage.
E). Activated charcoal and a saline cathartic.

Question 34 Answer: A). Administration of Flumazenil. AND D). Gastric lavage. AND E). Activated charcoal and a saline cathartic.
Question 34 Explanation: If ingestion is recent, decontamination of the GI system is indicated. The administration of syrup of ipecac is contraindicated because of aspiration risks related to sedation. Gastric lavage is generally the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Hemodialysis is not useful in the treatment of benzodiazepine overdose. Flumazenil can be used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.

Question 35. A patient has taken an overdose of aspirin. Which of the following should a nurse most closely monitor for during acute management of this patient?
A). Onset of pulmonary edema.
B). Respiratory alkalosis.
C). Metabolic alkalosis.
D). Parkinson’s disease type symptoms.

Question 35 Answer: D). Parkinson’s disease type symptoms.
Question 35 Explanation: Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development.

Question 36. To assist an adult client to sleep better the nurse recommends which of the following?
A). Eating a large meal 1 hour before bedtime.
B). Performing mild exercises 30 minutes before going to bed.
C). Consuming a small glass of warm milk at bedtime.
D). Drinking a glass of wine just before retiring to bed.

Question 36 Answer: C). Consuming a small glass of warm milk at bedtime.
Question 36 Explanation: A small glass of milk relaxes the body and promotes sleep.

Question 37. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
A). Somatic neuropathy.
B). Diabetic nephropathy.
C). Atherosclerosis.
D). Autonomic neuropathy.

Question 37 Answer: D). Autonomic neuropathy.
Question 37 Explanation: Autonomic neuropathy can cause inability to urinate.

Question 38. The nurse recognizes that a client is experiencing insomnia when the client reports(select all that apply):
A). Extended time to fall asleep.
B). Falling asleep at inappropriate times.
C). Feeling tired after a night’s sleep.
D). Difficulty staying asleep.

Question 38 Answer: A). Extended time to fall asleep. AND C). Feeling tired after a night’s sleep. AND D). Difficulty staying asleep.
Question 38 Explanation: These symptoms are often reported by clients with insomnia. Clients report nonrestorative sleep. Arising once at night to urinate (nocturia) is not in and of itself insomnia.

Question 39. A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4 year-old boy who is non-verbal. This child does not have on any identification. What should the nurse do?
A). Contact the provider.
B). Ask the father who is in the room the child’s name..
C). Ask the child to write their name on paper..
D). Ask a co-worker about the identification of the child..

Question 39 Answer: B). Ask the father who is in the room the child’s name..
Question 39 Explanation: In this case you are able to determine the name of the child by the father’s statement. You should not withhold the medication from the child following identification.

Question 40. A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training?
A). The age of the child.
B). Frequent attempts with positive reinforcement..
C). The overall mental and physical abilities of the child..
D). The child ability to understand instruction..

Question 40 Answer: C). The overall mental and physical abilities of the child..
Question 40 Explanation: Age is not the greatest factor in potty training. The overall mental and physical abilities of the child is the most important factor.

Question 41. A patient has recently experienced a (MI) within the last 4 hours. Which of the following medications would most like be administered?
A). Acetaminophen.
B). Coumadin.
C). Streptokinase.
D). Atropine.

Question 41 Answer: C). Streptokinase.
Question 41 Explanation: Streptokinase is a clot busting drug and the best choice in this

Question 42. Rho gam is most often used to treat____ mothers that have a ____ infant.
A). RH positive, RH positive.
B). RH negative, RH negative.
C). RH positive, RH negative.
D). RH negative, RH positive.

Question 42 Answer: D). RH negative, RH positive.
Question 42 Explanation: Rho gam prevents the production of anti-RH antibodies in the mother that has a Rh positive fetus.

Question 43. A 28 year old male has been found wandering around in a confused pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?
A). Blood sugar check.
B). Arterial blood gases.
C). Blood cultures.
D). CT scan.

Question 43 Answer: A). Blood sugar check.
Question 43 Explanation: With a history of diabetes, the first response should be to check blood sugar levels.

Question 44. A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?
A). Migranes.
B). Decreased HR.
C). Muscle weakness of the extremities.
D). Paresthesias.

Question 44 Answer: A). Migranes.
Question 44 Explanation: Decreased HR, paresthesias and muscle weakness of the extremities were symptoms of acute hyperkalemia.

Question 45. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
A). Multiple sclerosis.
B). Anorexia nervosa.
C). Systemic sclerosis.
D). Bulimia.

Question 45 Answer: B). Anorexia nervosa.
Question 45 Explanation: All of the clinical signs and systems point to a condition of anorexia nervosa.

Question 46. A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate?
A). Vastus medialis.
B). Gluteus minimus.
C). Gluteus maximus.
D). Vastus lateralis.

Question 46 Answer: D). Vastus lateralis.
Question 46 Explanation: Vastus lateralis is the most appropriate location.

Question 47. A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take?
A). Seek counseling.
B). Start prophylactic AZT treatment.
C). Start prophylactic Pentamide treatment.
D). Immediately see a social worker.

Question 47 Answer: B). Start prophylactic AZT treatment.
Question 47 Explanation: AZT treatment is the most critical innervention.

Question 48. A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
A). IgD.
B). IgG.
C). IgE.
D). IgA.

Question 48 Answer: B). IgG.
Question 48 Explanation: IgG is the only immunoglobulin that can cross the placental barrier.

Question 49. A fragile 87 year-old female has recently been admitted to the hospital with increased confusion and falls over last 2 weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?
A). ECG (electrocardiogram).
B). FBC (full blood count).
C). Thyroid function tests.
D). CT scan.

Question 49 Answer: D). CT scan.
Question 49 Explanation: A CT scan would be performed for further investigation of the hemiparesis.

Question 50. A 84 year-old male has been loosing mobility and gaining weight over the last 2 months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed?
A). ECG (electrocardiogram).
B). Thyroid function tests.
C). CT scan.
D). FBC (full blood count).

Question 50 Answer: B). Thyroid function tests.
Question 50 Explanation: Weight gain and poor temperature tolerance indicate something may be wrong with the thyroid function.

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