NCLEX-RN Practice Exam #07

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Published on February 8, 2017 by NCLEX Exams

NCLEX-RN Practice Exam #07 In Text Mode: All questions and answers are given for reading and answering at your own pace.

Question 1. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, It will be most important to teach the client and family about:
A). Oxygen therapy.
B). Conservation of energy.
C). Bleeding precautions.
D). Prevention of falls.

Question 1 Answer: C). Bleeding precautions.
Question 1 Explanation: The normal platelet count is 120,000–400, Bleeding occurs in clients with low platelets. The priority is to prevent and minimize bleeding. Oxygenation in oxygen therapy is important, but platelets do not carry oxygen. Prevention of falls and conservation of energy are of lesser priority and are incorrect in this instance.

Question 2. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following?
A). “I guess my child needs to understand what the word ‘hot’ means.”.
B). “We will be sure that our child stays in his room when we work in the kitchen.”.
C). “We will be sure to not leave hot liquids unattended.”.
D). “We will install a safety gate as soon as we get home so that our child can’t get into the kitchen.”.

Question 2 Answer: C). “We will be sure to not leave hot liquids unattended.”.
Question 2 Explanation: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners on the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. All other answer choices do not reflect an adequate understanding of the principles of safety.

Question 3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
A). Administering Tylenol as ordered.
B). Encouraging fluid intake of at least 200mL per hour.
C). Taking hourly blood pressures with mechanical cuff.
D). Position in high Fowler’s with knee gatch raised.

Question 3 Answer: B). Encouraging fluid intake of at least 200mL per hour.
Question 3 Explanation: It is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood. Taking hourly blood pressures with mechanical cuff is incorrect because a mechanical cuff places too much pressure on the arm. Position in high Fowler’s with knee gatch raised is incorrect because raising the knee gatch impedes circulation. Administering Tylenol as ordered is incorrect because Tylenol is too mild an analgesic for the client in crisis.

Question 4. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?
A). Elevate the head of the bed 30°.
B). Encourage the Valsalva maneuver for bowel movements.
C). Encourage coughing and deep breathing every 2 hours.
D). Place the client in Trendelenburg position for postural drainage.

Question 4 Answer: A). Elevate the head of the bed 30°.
Question 4 Explanation: Elevating the head of the bed 30° avoids pressure on the sella turcica and alleviates headaches. Trendelenburg, Valsalva maneuver, and coughing are incorrect because all increase the intracranial pressure.

Question 5. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
A). Chicken salad sandwich, coleslaw, French fries, ice cream.
B). Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie.
C). Pork chop, creamed potatoes, corn, and coconut cake.
D). Roast beef, gelatin salad, green beans, and peach pie.

Question 5 Answer: B). Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie.
Question 5 Explanation: Egg yolks, wheat bread, carrots, raisins, and green, leafy vegetables are all high in iron, which is an important mineral for this client. Roast beef, cabbage, and pork chops are also high in iron, but the side dishes accompanying these choices are not.

Question 6. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:
A). Output.
B). Temperature.
C). Specific gravity.
D). Blood pressure.

Question 6 Answer: D). Blood pressure.
Question 6 Explanation: Blood pressure is the best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity. Temperature would be an indicator of infection, decreased output would be a clinical manifestation but would take longer to occur than blood pressure changes, and specific gravity changes occur with other disorders.

Question 7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
A). Traveling by airplane for business trips.
B). A bus trip to the Museum of Natural History.
C). A family vacation in the Rocky Mountains.
D). Chaperoning the local boys club on a snow-skiing trip.

Question 7 Answer: B). A bus trip to the Museum of Natural History.
Question 7 Explanation: Taking a trip to the museum is the only answer that does not pose a threat. A family vacation in the Rocky Mountains at high altitudes, cold temperatures, and airplane travel can cause sickling episodes and should be avoided.

Question 8. An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
A). Shins.
B). Conjunctiva of the eye.
C). Roof of the mouth.
D). Soles of the feet.

Question 8 Answer: C). Roof of the mouth.
Question 8 Explanation: The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons. The conjunctiva can have normal deposits of fat, which give a yellowish hue; thus, conjunctiva of the eye is incorrect. The soles of the feet can be yellow if they are calloused, making soles of the feet incorrect; the shins would be an area of darker pigment, so shins is incorrect.

Question 9. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
A). The client recently lost his job as a postal worker..
B). The client had radiation for treatment of Hodgkin’s disease as a teenager.
C). The client collects stamps as a hobby..
D). The client’s brother had leukemia as a child..

Question 9 Answer: B). The client had radiation for treatment of Hodgkin’s disease as a teenager.
Question 9 Explanation: Radiation treatment for other types of cancer can result in leukemia. Some hobbies and occupations involving chemicals are linked to leukemia, but not the ones in these answers; therefore, collecting stamps as a hobby and losing job as a postal worker are incorrect. The client’s brother had leukemia as a child is incorrect because the incidence of leukemia is higher in twins than in siblings.

Question 10. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply.
A). Increased need to protect the client.
B). Failure to replace body fluids.
C). Increased risk of hypotension.
D). Lack of follow-up nursing actions.
E). Excessive bumetanide administration.
F). Failure to teach the client adequately.

Question 10 Answer: A). Increased need to protect the client. AND C). Increased risk of hypotension. AND D). Lack of follow-up nursing actions. AND F). Failure to teach the client adequately.
Question 10 Explanation: To prove malpractice against a nurse, the plaintiff must prove that the nurse owed a duty to the client, that the nurse breached the duty, and that as a result harm was caused to person or property. The client has an increased risk of hypotension because hypotension is a common adverse effect of bumetanide, this is the second dose within 4 hours, and the client has heart failure. The client can prove that the nurse did not protect him by failing to provide adequate teaching and perform correct and timely nursing interventions after administering the bumetanide. After the first 15-minute check, the nurse should continue increased client monitoring to ensure client compliance with safety measures. Replacing fluid volume is not the issue; furthermore, the goal of therapy is to reduce total body fluid. No data indicate that the dose of bumetanide, a loop diuretic, was excessive. However, because this medication can cause hypotension, especially after a repeat dose, the nurse should instruct the client to remain in bed and provide him with a urinal. It may be difficult for the client to prove that the second dose of bumetanide caused the injury.

Question 11. A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?
A). Fatigue related to chemotherapy.
B). Sexual dysfunction related to radiation therapy.
C). Anticipatory grieving related to terminal illness.
D). Tissue integrity related to prolonged bed rest.

Question 11 Answer: B). Sexual dysfunction related to radiation therapy.
Question 11 Explanation: Radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices. Hodgkin’s disease, however, has a good prognosis when diagnosed early. Anticipatory grieving related to terminal illness, Tissue integrity related to prolonged bed rest, and Fatigue related to chemotherapy are incorrect because they are of lesser priority.

Question 12. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
A). The soles of the feet.
B). The thorax.
C). The abdomen.
D). The earlobes.

Question 12 Answer: A). The soles of the feet.
Question 12 Explanation: Petechiae are not usually visualized on dark skin. The soles of the feet and palms of the hand provide a lighter surface for assessing the client for petechiae. The abdomen, thorax , and earlobes are incorrect because the skin might be too dark to make an assessment.

Question 13. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?
A). Obtain a crash cart.
B). Assess the blood pressure for hypertension.
C). Check the calcium level.
D). Assess the dressing for drainage.

Question 13 Answer: C). Check the calcium level.
Question 13 Explanation: The parathyroid glands are responsible for calcium production and can be damaged during a thyroidectomy. The tingling is due to low calcium levels. The crash cart would be needed in respiratory distress but would not be the next action to take; thus, obtaining a crash cart is incorrect. Hypertension occurs in thyroid storm and the drainage would occur in hemorrhage, so assessing the dressing for drainage and assessing the blood pressure for hypertension are incorrect.

Question 14. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
A). Lima beans.
B). Cottage cheese.
C). Peaches.
D). Popsicle.

Question 14 Answer: D). Popsicle.
Question 14 Explanation: Hydration is important in the client with sickle cell disease to prevent thrombus formation. Popsicles, gelatin, juice, and pudding have high fluid content. The foods in peaches , cottage cheese , and lima beans do not aid in hydration and are, therefore, incorrect.

Question 15. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
A). Give a bolus of IV fluids.
B). Adjust the room temperature.
C). Administer meperidine (Demerol) 75mg IV push.
D). Start O2.

Question 15 Answer: D). Start O2.
Question 15 Explanation: The most prominent clinical manifestation of sickle cell crisis is pain. However, the pulse oximetry indicates that oxygen levels are low; thus, oxygenation takes precedence over pain relief. Adjusting the room temperature is incorrect because although a warm environment reduces pain and minimizes sickling, it would not be a priority. Giving a bolus of IV fluids is incorrect because although hydration is important, it would not require a bolus. Administering meperidine (Demerol) 75mg IV push is incorrect because Demerol is acidifying to the blood and increases sickling.

Question 16. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice?
A). Nursing staff are led by a nurse when providing care to a group of clients..
B). A task approach method is used to provide care to clients..
C). A single registered nurse is responsible for providing nursing care to a group of clients..
D). Managed care concepts and tools are used when providing client care..

Question 16 Answer: A). Nursing staff are led by a nurse when providing care to a group of clients..
Question 16 Explanation: In team nursing, nursing personnel are led by a nurse when providing care to a group of clients. A task approach method is used to provide care to clients- identifies functional nursing. Managed care concepts and tools used when providing client care – identifies a component of case management. The statement a single registered nurse is responsible for providing nursing care to a group of clients- identifies primary nursing.

Question 17. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
A). Take the blood pressure.
B). Examine the tongue.
C). Examine the feet for petechiae.
D). Palpate the spleen.

Question 17 Answer: B). Examine the tongue.
Question 17 Explanation: The tongue is smooth and beefy red in the client with vitamin B12 deficiency, so examining the tongue should be included in the physical assessment. Bleeding, splenomegaly, and blood pressure changes do not occur, making palpating the spleen ,taking the blood pressure and examining the feet for petechiae incorrect.

Question 18. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant?
A). A client who is receiving continuous tube feedings.
B). A client who requires wound irrigation.
C). A client who requires frequent ambulation.
D). A client who requires frequent vital signs after a cardiac catheterization.

Question 18 Answer: C). A client who requires frequent ambulation.
Question 18 Explanation: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for a nursing assistant would be to care for the client who requires frequent ambulation. The nursing assistant is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

Question 19. A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?
A). Sodium and potassium levels monitored.
B). Intake/output measurements.
C). Daily weights.
D). Glucometer readings as ordered.

Question 19 Answer: D). Glucometer readings as ordered.
Question 19 Explanation: IV glucocorticoids raise the glucose levels and often require coverage with insulin. Answer B is not necessary at this time, sodium and potassium levels would be monitored when the client is receiving mineral corticoids, and daily weights is unnecessary.

Question 20. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
A). Semi-Fowler’s with legs extended on the bed.
B). Side-lying with knees flexed.
C). Knee-chest.
D). High Fowler’s with knees flexed.

Question 20 Answer: A). Semi-Fowler’s with legs extended on the bed.
Question 20 Explanation: Placing the client in semi-Fowler’s position provides the best oxygenation for this client. Flexion of the hips and knees, which includes the knee-chest position, impedes circulation and is not correct positioning for this client.

Question 21. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
A). Measure the urinary output.
B). Encourage increased fluid intake.
C). Check the vital signs.
D). Weigh the client.

Question 21 Answer: C). Check the vital signs.
Question 21 Explanation: The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output is important, but the stem already says that the client has polyuria, so measuring the urinary output is incorrect. Encouraging fluid intake will not correct the problem.Weighing the client is incorrect because it is not necessary at this time.

Question 22. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
A). “I will use an electric razor for shaving.”.
B). “I will drink 500mL of fluid or less each day.”.
C). “I will wear support hose when I am up.”.
D). “I will eat foods low in iron.”.

Question 22 Answer: B). “I will drink 500mL of fluid or less each day.”.
Question 22 Explanation: The client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in preventing clot formation, so the statement to drink less than 500mL is incorrect. Wearing support hose when I am up, using an electric razor for shaving, and eating foods low in iron are incorrect because they all contribute to the prevention of complications. Support hose promotes venous return, the electric razor prevents bleeding due to injury, and a diet low in iron is essential to preventing further red cell formation.

Question 23. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
A). “Have you noticed changes in your alertness?”.
B). “Have you noticed a change in sleeping habits recently?”.
C). “Have you had a respiratory infection in the last 6 months?”.
D). “Have you lost weight recently?”.

Question 23 Answer: C). “Have you had a respiratory infection in the last 6 months?”.
Question 23 Explanation: The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations.

Question 24. A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:
A). White blood cell count.
B). Potassium levels.
C). Partial prothrombin time (PTT).
D). Platelet count.

Question 24 Answer: D). Platelet count.
Question 24 Explanation: Clients with autoimmune thrombocytopenic purpura (ATP) have low platelet counts, making platelet count the correct answer. White cell counts, potassium levels, and PTT are not affected in ATP.

Question 25. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
A). Respirations 28 shallow.
B). Weight gain of 10 pounds in 6 months.
C). BP 146/88.
D). Pink complexion.

Question 25 Answer: A). Respirations 28 shallow.
Question 25 Explanation: When there are fewer red blood cells, there is less hemoglobin and less oxygen. Therefore, the client is often short of breath, as indicated in respirations, 28, shallow . The client with anemia is often pale in color, has weight loss, and may be hypotensive. BP of 146/88 , weight gain of 10 pounds in 6 months , and pink complexion are within normal and, therefore, are incorrect.

Question 26. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
A). Capillary refill of.
B). Sensation reported when soles of feet are touched.
C). Toes moved in active range of motion.
D). Body temperature of 99°F or less.

Question 26 Answer: A). Capillary refill of.
Question 26 Explanation: It is important to assess the extremities for blood vessel occlusion in the client with sickle cell anemia because a change in capillary refill would indicate a change in circulation. Body temperature, motion, and sensation would not give information regarding peripheral circulation; therefore, body temperature of 99°F or less , toes moved in active range of motion, and sensation reported when soles of feet are touched are incorrect.

Question 27. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?
A). Place the client in a sitting position with the head hyperextended.
B). Apply ice packs to the forehead and back of the neck.
C). Pack the nares tightly with gauze to apply pressure to the source of bleeding.
D). Pinch the soft lower part of the nose for a minimum of 5 minutes.

Question 27 Answer: D). Pinch the soft lower part of the nose for a minimum of 5 minutes.
Question 27 Explanation: The client should be positioned upright and leaning forward, to prevent aspiration of blood. Placing the client in a sitting position with the head hyperextended , packing the nares tightly with gauze to apply pressure to the source of bleeding , and applying ice packs to the forehead and back of the neck are incorrect because direct pressure to the nose stops the bleeding, and ice packs should be applied directly to the nose as well. If a pack is necessary, the nares are loosely packed.

Question 28. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
A). Risk for injury related to thrombocytopenia.
B). Fatigue related to the disease process.
C). Interrupted family processes related to life-threatening illness of a family member.
D). Oral mucous membrane, altered related to chemotherapy.

Question 28 Answer: A). Risk for injury related to thrombocytopenia.
Question 28 Explanation: The client with acute leukemia has bleeding tendencies due to decreased platelet counts, and any injury would exacerbate the problem. The client would require close monitoring for hemorrhage, which is of higher priority than the diagnoses : Oral mucous membrane, altered related to chemotherapy ,Fatigue related to the disease process and Interrupted family processes related to life-threatening illness of a family member .

Question 29. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
A). Decreased cardiac output r/t bradycardia.
B). Impaired physical mobility related to decreased endurance.
C). Hypothermia r/t decreased metabolic rate.
D). Disturbed thought processes r/t interstitial edema.

Question 29 Answer: A). Decreased cardiac output r/t bradycardia.
Question 29 Explanation: The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices.

Question 30. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply.
A). Gastrointestinal.
B). Sexual contact with an infected individual.
C). Inhalation.
D). Skin.
E). Direct contact with an infected individual.
F). Kissing.

Question 30 Answer: A). Gastrointestinal. AND C). Inhalation. AND D). Skin.
Question 30 Explanation: Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person.

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