NCLEX-RN Practice Exam #08 In Text Mode: All questions and answers are given for reading and answering at your own pace.
Question 1. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
B). Shrimp with rice.
C). Turkey breast.
D). Macaroni and cheese.
Question 1 Answer: C). Turkey breast.
Question 1 Explanation: Turkey contains the least amount of fats and cholesterol. Liver, eggs, beef, cream sauces, shrimp, cheese, and chocolate should be avoided by the client. The client should bake meat rather than frying to avoid adding fat to the meat during cooking.
Question 2. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?
B). Urinary incontinence.
Question 2 Answer: C). Nausea.
Question 2 Explanation: Nausea and gastrointestinal upset are very common in clients taking acetlcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness. The client might already be experiencing urinary incontinence or headaches, but they are not necessarily associated; and the client with Alzheimer’s disease is already confused. Therefore, urinary incontinence, headaches , and confusion are incorrect.
Question 3. The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:
A). Phlebostatic axis.
B). Erb’s point.
C). Tail of Spence.
Question 3 Answer: A). Phlebostatic axis.
Question 3 Explanation: The phlebostatic axis is located at the fifth intercostals space midaxillary line and is the correct placement of the manometer. The PMI or point of maximal impulse is located at the fifth intercostals space midclavicular line. Erb’s point is the point at which you can hear the valves close simultaneously. The Tail of Spence (the upper outer quadrant) is the area where most breast cancers are located and has nothing to do with placement of a manometer.
Question 4. The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:
Question 4 Answer: C). Apraxia.
Question 4 Explanation: Apraxia is the inability to use objects appropriately. Agnosia is loss of sensory comprehension, anomia is the inability to find words, and aphasia is the inability to speak or understand .
Question 5. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:
A). Check the client for bladder distention.
B). Assess the blood pressure for hypotension.
C). Determine whether an oxytocic drug was given.
D). Check for the expulsion of small clots.
Question 5 Answer: A). Check the client for bladder distention.
Question 5 Explanation: If the fundus of the client is displaced to the side, this might indicate a full bladder. The next action by the nurse should be to check for bladder distention and catheterize, if necessary. Other answer choices are actions that relate to postpartal hemorrhage.
Question 6. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:
A). Newborn skin is easily traumatized by washing..
B). The chance of chilling the baby outweighs the benefits of bathing..
C). New parents need time to learn how to hold the baby..
D). The umbilical cord needs time to separate..
Question 6 Answer: D). The umbilical cord needs time to separate..
Question 6 Explanation: The umbilical cord needs time to dry and fall off before putting the infant in the tub. Although other choices might be important, they are not the primary answer to the question.
Question 7. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.
A). “I need to pace my activities throughout the day.”.
B). “I should exercise in the evening to encourage a good sleep pattern.”.
C). “I enjoy exercising but I need to be careful.”.
D). “I need to limit playing football to only the weekends.”.
E). “I should gauge my activity level by my energy level.”.
Question 7 Answer: B). “I should exercise in the evening to encourage a good sleep pattern.”. AND D). “I need to limit playing football to only the weekends.”.
Question 7 Explanation: The client should be instructed to avoid high-impact activity or contact sports such as football. Exercising late in the evening may interfere with restful sleep. The client with hyperparathyroidism should pace activities throughout the day and plan for periods of uninterrupted rest. The client should plan for at least 30 minutes of walking each day to support calcium movement into the bones. The client should be instructed to use energy level as a guide to activity.
Question 8. The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?
A). “You know you had breakfast 30 minutes ago.”.
B). “You will have to wait a while; lunch will be here in a little while.”.
C). “I’ll get you some juice and toast. Would you like something else?”.
D). “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”.
Question 8 Answer: C). “I’ll get you some juice and toast. Would you like something else?”.
Question 8 Explanation: The client who is confused might forget that he ate earlier. Don’t argue with the client. Simply get him something to eat that will satisfy him until lunch. Statements, “You know you had breakfast 30 minutes ago.” and “You will have to wait a while; lunch will be here in a little while” are incorrect because the nurse is dismissing the client. Statement, “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.” is validating the delusion.
Question 9. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:
A). With each meal.
B). 30 minutes before meals.
C). 30 minutes after meals.
D). In a single dose at bedtime.
Question 9 Answer: A). With each meal.
Question 9 Explanation: Proton pump inhibitors such as Nexium and Protonix should be taken with meals, for optimal effect. Histamine-blocking agents such as Zantac should be taken 30 minutes before meals, so taking 30 minutes before meals is incorrect. Tagamet can be taken in a single dose at bedtime, taking in a single dose at bedtime incorrect. Taking 30 minutes after meals does not treat the problem adequately and, therefore, is incorrect.
Question 10. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.
A). Monitor the client’s ability to void..
B). Monitor the client’s ability to move the extremities..
C). Inspect the puncture site for swelling, redness, and drainage..
D). Maintain the client on a nothing-by-mouth (NPO) status for 24 hours..
E). Maintain the client in a flat position..
F). Restrict fluid intake for a period of 2 hours..
Question 10 Answer: A). Monitor the client’s ability to void.. AND B). Monitor the client’s ability to move the extremities.. AND C). Inspect the puncture site for swelling, redness, and drainage.. AND E). Maintain the client in a flat position..
Question 10 Explanation: Following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the health care provider’s prescriptions. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client’s condition. The nurse checks the puncture site for redness and drainage, and monitors the client’s ability to void and move the extremities.
Question 11. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
A). Place the client in Trendelenburg position.
B). Utilize an infusion pump.
C). Check the blood glucose level.
D). Cover the solution with foil.
Question 11 Answer: C). Check the blood glucose level.
Question 11 Explanation: Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped. Utilizing an infusion pump is incorrect because the hyperstat is given by IV push. The client should be placed in dorsal recumbent position, not a Trendelenburg position. Covering the solution with foil is incorrect because the medication does not have to be covered with foil.
Question 12. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients?
A). A client complaining of muscle aches, a headache, and malaise.
B). A client with a minor laceration on the index finger sustained while cutting an eggplant.
C). A client who twisted her ankle when she fell while rollerblading.
D). A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.
Question 12 Answer: D). A client with chest pain who states that he just ate pizza that was made with a very spicy sauce.
Question 12 Explanation: In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care. The type of illness, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as non urgent, and they are the number 3 priority.
Question 13. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
A). “I can save my dessert from supper for a bedtime snack.”.
B). “I will need to carry candy or some form of sugar with me all the time.”.
C). “I will make sure I eat breakfast within 10 minutes of taking my insulin.”.
D). “I will eat a snack around three o’clock each afternoon.”.
Question 13 Answer: C). “I will make sure I eat breakfast within 10 minutes of taking my insulin.”.
Question 13 Explanation: Novalog insulin onsets very quickly, so food should be available within 10–15 minutes of taking the insulin. Answer “I will need to carry candy or some form of sugar with me all the time.” does not address a particular type of insulin, so it is incorrect. NPH insulin peaks in 8–12 hours, so a snack should be eaten at the expected peak time. It may not be 3 p.m. as stated in answer “I will eat a snack around three o’clock each afternoon.” . Answer “I can save my dessert from supper for a bedtime snack.” is incorrect because there is no need to save the dessert until bedtime.
Question 14. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
A). Question the order.
B). Administer the medications.
C). Administer separately.
D). Contact the pharmacy.
Question 14 Answer: B). Administer the medications.
Question 14 Explanation: Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix for hypertension. Questioning the order , administering separately , and contacting the pharmacy are incorrect because the order is accurate. There is no need to question the order, administer the medication separately, or contact the pharmacy.
Question 15. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:
A). Superinfection due to low CD4 count.
C). Reaction to antiviral medication.
Question 15 Answer: B). Tuberculosis.
Question 15 Explanation: A low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with tuberculosis. If the answer in pneumonia had said pneumocystis pneumonia, pneumonia would have been consistent with the symptoms given in the stem, but just saying pneumonia isn’t specific enough to diagnose the problem. Reaction to antiviral medication and superinfection due to low CD4 count are not directly related to the stem.
Question 16. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?
A). Respiratory rate of 30 per minute.
B). Blood glucose of 110mg/dL.
C). Heart rate of 60bpm.
D). Blood pressure of 126/80.
Question 16 Answer: C). Heart rate of 60bpm.
Question 16 Explanation: A heart rate of 60 in the baby should be reported immediately. The dose should be held if the heart rate is below 100bpm. The blood glucose, blood pressure, and respirations are within normal limits; thus answers are incorrect.
Question 17. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
A). Take one every 15 minutes if pain occurs.
B). Crush the medication and take with water.
C). Replenish his supply every 3 months.
D). Leave the medication in the brown bottle.
Question 17 Answer: D). Leave the medication in the brown bottle.
Question 17 Explanation: Nitroglycerine should be kept in a brown bottle (or even a special air- and water-tight, solid or plated silver or gold container) because of its instability and tendency to become less potent when exposed to air, light, or water. The supply should be replenished every 6 months, not 3 months, and one tablet should be taken every 5 minutes until pain subsides, so answers replenishing his supply every 3 months and taking one every 15 minutes if pain occurs are incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed.
Question 18. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?
A). Roast beef sandwich, potato chips, pickle spear, iced tea.
B). Hamburger, baked beans, fruit cup, iced tea.
C). Tomato soup, cheese toast, Jello, coffee.
D). Split pea soup, mashed potatoes, pudding, milk.
Question 18 Answer: D). Split pea soup, mashed potatoes, pudding, milk.
Question 18 Explanation: The client with a facial stroke will have difficulty swallowing and chewing, and the foods split pea soup, mashed potatoes, pudding, milk provide the least amount of chewing. Other choices in the question would require more chewing and, thus, are incorrect.
Question 19. A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
A). Hib titer.
C). Hepatitis B vaccine.
D). Mumps vaccine.
Question 19 Answer: A). Hib titer.
Question 19 Explanation: The Hemophilus influenza vaccine is given at 4 months with the polio vaccine. Other choices are incorrect because these vaccines are given later in life.
Question 20. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?
A). Cluster headaches.
D). Prinzmetal’s angina.
Question 20 Answer: D). Prinzmetal’s angina.
Question 20 Explanation: If the client has a history of Prinzmetal’s angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms. There is no contraindication for taking triptan drugs in clients with diabetes, cancer, or cluster headaches .
Question 21. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
Question 21 Answer: A). Neck.
Question 21 Explanation: The jugular veins in the neck should be assessed for distension. The other parts of the body will be edematous in right-sided congestive heart failure, not left-sided; thus, feet, hands, and sacrum are incorrect.
Question 22. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.
A). Administering furosemide (Lasix).
B). Administering morphine sulfate intravenously.
C). Transporting the client to the coronary care unit.
D). Inserting a Foley catheter.
E). Administering oxygen.
F). Placing the client in a low Fowler’s side-lying position.
Question 22 Answer: A). Administering furosemide (Lasix). AND B). Administering morphine sulfate intravenously. AND D). Inserting a Foley catheter. AND E). Administering oxygen.
Question 22 Explanation: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler’s position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful.
Question 23. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
A). Take the medication with fruit juice..
B). Report muscle weakness to the physician..
C). Allow six months for the drug to take effect..
D). Ask the doctor to perform a complete blood count before starting the medication..
Question 23 Answer: B). Report muscle weakness to the physician..
Question 23 Explanation: The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so allowing six months for the drug to take effect is incorrect. The medication should be taken with water because fruit juice, particularly grapefruit, can decrease the effectiveness, making take the medication with fruit juice. incorrect. Liver function studies should be checked before beginning the medication, not after the fact, making ask the doctor to perform a complete blood count before starting the medication incorrect.
Question 24. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
A). His wife will rest much better knowing that he is at home..
B). There is no need for him to stay because staffing is adequate..
C). Visitation is limited to 30 minutes when the implant is in place..
D). Overnight stays by family members is against hospital policy..
Question 24 Answer: C). Visitation is limited to 30 minutes when the implant is in place..
Question 24 Explanation: Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Other choices are not empathetic and do not address the question; therefore, they are incorrect.
Question 25. The best method of evaluating the amount of peripheral edema is:
A). Measuring the intake and output.
B). Checking for pitting edema.
C). Weighing the client daily.
D). Measuring the extremity.
Question 25 Answer: D). Measuring the extremity.
Question 25 Explanation: The best indicator of peripheral edema is measuring the extremity. A paper tape measure should be used rather than one of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment. Weighing the client daily is incorrect because it will not indicate peripheral edema. Measuring the intake and output is incorrect because it will not indicate peripheral edema. Checking for pitting edema is incorrect it is less reliable than measuring with a paper tape measure.
Question 26. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:
A). Pain on flexion of the hip and knee.
B). Pain when the head is turned to the left side.
C). Dizziness when changing positions.
D). Nuchal rigidity on flexion of the neck.
Question 26 Answer: A). Pain on flexion of the hip and knee.
Question 26 Explanation: Kernig’s sign is positive if pain occurs on flexion of the hip and knee. The Brudzinski reflex is positive if pain occurs on flexion of the head and neck onto the chest so nuchal rigidity on flexion of the neck is incorrect. Pain when the head is turned to the left side and dizziness when changing positions might be present but are not related to Kernig’s sign.
Question 27. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
A). Tell the client to calm down and ask him if he would like to play cards..
B). Leave the client alone until he calms down.
C). Tell the client that if he continues his behavior he will be punished..
D). Call security for assistance and prepare to sedate the client..
Question 27 Answer: D). Call security for assistance and prepare to sedate the client..
Question 27 Explanation: If the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate him. Telling the client to calm down and ask him if he would like to play cards is incorrect because simply telling the client to calm down will not work. Telling the client that if he continues his behavior he will be punished is incorrect because telling the client that if he continues he will be punished is a threat and may further anger him. Leaving the client alone until he calms down is incorrect because if the client is left alone he might harm himself.
Question 28. A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:
A). Reverse drug toxicity and prevent tissue damage.
B). Create a synergistic effect that shortens treatment time.
C). Increase the number of circulating neutrophils.
D). Treat iron-deficiency anemia caused by chemotherapeutic agents.
Question 28 Answer: A). Reverse drug toxicity and prevent tissue damage.
Question 28 Explanation: Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative. Other choices are incorrect because Leucovorin does not treat iron deficiency, increase neutrophils, or have a synergistic effect.
Question 29. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action?
A). Decline to sign the will..
B). Sign the will as a witness to the signature only..
C). Sign the will, clearly identifying credentials and employment agency..
D). Call the hospital lawyer before signing the will..
Question 29 Answer: A). Decline to sign the will..
Question 29 Explanation: Living wills are required to be in writing and signed by the client. The client’s signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including a nurse in a facility in which the client is receiving care.
Question 30. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:
B). Normal aging.
D). Chronic fatigue syndrome.
Question 30 Answer: A). Sundowning.
Question 30 Explanation: Increased confusion at night is known as “sundowning” syndrome. This increased confusion occurs when the sun begins to set and continues during the night. Chronic fatigue syndrome is incorrect because fatigue is not necessarily present. Increased confusion at night is not part of normal aging; therefore, normal aging is incorrect. A delusion is a firm, fixed belief; therefore, delusions is incorrect.